Paul Mears: ICSs need vision, leadership and to challenge norms

Daniel Reynolds

Hello and welcome to Health on the Line. I'm Daniel Reynolds, director of communications at the NHS Confederation. Coming up shortly, our chief executive Matthew Taylor talks to Paul Mears, an experienced NHS leader who has worked in both the English and now Welsh health systems about how to deliver better integrated health and care, drawing on his experiences of both systems. 

But first, I'm delighted to be joined by Chris Thomas from the Institute for Public Policy Research, the IPPR, who's going to talk to us about a new report that the NHS Confederation and IPPR have just published on the role of the NHS in supporting social and economic development. As part of its mission-driven approach, the new government has been explicit about how it sees the NHS as an engine of economic growth.

In fact, in one of Wes Streeting's first speeches since he became Secretary of State, he made clear that the Department of Health and Social Care is an economic growth department, saying that the health of the nation and the health of the economy are inextricably linked. This has been a major focus of the IPPR's commission on health and prosperity, which is a landmark cross-party initiative that explores the links between health and prosperity.

As part of the commission, my colleagues at the Confed have worked with Chris and the IPPR to engage with integrated care systems in England and a health board in Wales to understand the practical changes that local systems can make to deliver on this agenda. Their new report published a few days ago is a great read. As head of the IPPR's commission and co-author of our new report, Chris is here to tell us more. Chris, welcome.

Chris Thomas

Hi Daniel, thanks for having me. 

Daniel Reynolds

So Chris, can we start with your assessment of the government's ambitions in this area? As you know, organisations like the Confed and IPPR have long been making the case for the NHS to be regarded as a key driver of economic activity and not to be seen as a drain on scarce public resources. But from what you've heard from Wes Streeting and other ministers so far, how confident are you that the new government will grip this agenda?

Chris Thomas

Yeah, really good question. Very, very encouraged is the answer. So I think it always bears repeating the size of the challenge, right? The assessment we have at the moment of the UK, and I'm sure this is similar for NHS Confederation, is that we really are the sick man of Europe. A lot of our outcomes are flashing red and they're behind other comparable countries. And then the damage that's doing to the economy is very profound.

One of the clearest ways that happens is that if someone's unwell, they can't get the support they need, they're on a waiting list for a long time, they don't have the support that they need in their work as well, then they'd probably fall out the labour market. They fall out the labour market, then we know that's one of the biggest drags on economic growth that exists at the moment. 

And then in turn, if there isn't growth, then much harder to invest in public services. And so that vicious circle kind of turns. But the encouraging news really is that that seems to have been recognised as an argument. Look, there was some encouraging news even before the election, from my point of view, that we had organisations, really important economic institutions like the OBR, the IMF, the Bank of England, all of them talking about the importance of health and suggesting that the UK needed to prioritise this. 

We've seen in the first days of the new government, Wes Streeting talk about the Department of Health and Social Care as an economic growth department. I think that's very encouraging. And they're beginning to flesh out now what that looks like.

So we have the foundations, I think, for this kind of link between health and the economy to be understood. For that to start to mean that we see health as an investment, not just as something we can only spend money on when the sun is shining, the economy is good, as a luxury item, basically, and we see it as a necessity, that would be really good. 

And obviously now the test of that aspiration is the extent to which one, that has followed through, will be looking to things like fiscal events. But to the extent to which government follow through on their promise and give others, including systems, the tools to begin to act on some of this and to deliver prosperity in their own places, in their own ways. 

We'll hope to see more on that in the months and years to come. 

Daniel Reynolds

I do feel for colleagues like you and my colleague here at the Confed, Michael Wood, your time has come because I know you've been making the case for this for many, many years. So I think the kind of change in rhetoric and approach from the government is very welcome in this area.

As you know, we've conducted our own analysis with Carnal Farah on the clear return on investment for the wider economy that you get when you invest in healthcare. So Chris, what do you see as the potential for the NHS and in particular, integrated care systems in driving economic growth? 

Chris Thomas

Yeah, huge potential. So worth me saying the work with Carnal Farah that the NHS Confederation have done is very impressive and I think makes the point very powerfully that if we invest properly in the NHS, then we get returns on that investment. 

And if we do that strategically, I mean, we think about things like investing, particularly in primary care, community care, general practice, then we get even better outcomes. So that's a really good foundation of evidence to go from. 

I think there are a few big channels for the NHS and ICSs to think about, many of which the ICSs are incredibly well placed to prioritise.

There's obviously huge promise in prevention. One of the things that I think is underpinning the fact that at the moment we have this kind of high and rising rate of economic inactivity due to sickness isn't just the pressure on the NHS. It's also that there's been this kind of failure to do prevention over a long period of time, partly about public health and population health as an agenda. But of course, ICS should be brilliantly placed and a really important system to get some of that moving in the right direction. 

But the other place that I think is really important is the ability that the NHS has to work with employment services and with the work agenda to create new care models and to bring those two things in more integrated way together. Some of the most exciting initiatives I can see in the NHS are those where, say, South London and Maudsley, where they're thinking through very carefully how to bring employment services into primary care; in Glasgow, where they're thinking about how to make sure that employment and finance are a key part of how the NHS approaches people after a diagnosis, in that case, a cancer diagnosis, and how they bring partners in to support that process. 

How in Leeds, they've been thinking differently about how they upscale people to make sure that when they come to recruit through anchor institutions that people have proactively been kind of upskilled in a way that makes jobs in the NHS and other public services possible. 

So those are some big opportunities treatment, yes, prevention, definitely, but also just different ways of thinking about what the NHS can do with others in partnership as an employer as an anchor. These are all really exciting ways that health and prosperity gives us ways to get into different ways of working, I think. 

Daniel Reynolds

I think it's one of the best things about the report. You talk through local areas that are making some really practical changes. You also talk about what are the key guiding principles for local systems to follow. I think there's six of them that you talk through. So can you just give the listeners a bit of a flavour of what those principles are, please, Chris? 

Chris Thomas

Yeah, of course. So Daniel, I won't try to test my memory and list all six, but I'll give some of the ones that feel really important; of course they're all important.

The core premise of the principles that we set out, and this was interesting because it's a hypothesis we genuinely tested in the research that sits behind this report. But the things we set out are basically that structures and governance do not a successful integrated care system make on their own. I think listeners will intuitively understand that, right? 

I think it's brilliant that ICS have statutory footing, it's a big opportunity, but just the creation of integrated care systems is not enough in its own right. Some act of parliament doesn't make the promise, the theoretical promise that they have become reality. 

So our principles are really all about what do we need to do beyond structure, beyond process, beyond governance that will really make a difference? And I think some that feel particularly critical to me, particularly given some of the case studies I've just talked about, are the ICP needs to be a really central partnership driving forum in a way that kind of means giving it some clout. 

We talk about starting with what's strong. And that's really a message that every place that we went to and talked to had strengths, massive strengths, and employing those can be really, really effective. 

We also talk about building those strengths and that the NHS has a role as a kind of big institution in lots of places of investing in strengths and making sure that thriving, you know, population health ecosystem is there, whether that's working with VCSOs or charities or others within the system. 

Sharing resources and particularly linking to communities, getting ideas from communities. We can often think of the NHS as very top-down idea goes from centre to system to place some of the best things systems are doing, reversing that, starting with communities and engaging their communities really effectively.

And cultural change, that lots of system working needs a different way of thinking that is perhaps not that dissimilar to the kind of dead pan vision of the NHS from 1948 and that the best ICS thinking very carefully or there are brilliant examples of ICS thinking very carefully about how to do that cultural change. 

Daniel Reynolds

I think that that leads brilliantly to the last question because we know the government has a big devolution agenda and we really hope there will genuinely be opportunities for local systems to take on more control and more autonomy. But it won't surprise our listeners when I say that governments of all political persuasions in the last 25, 30 years haven't done enough to empower local leaders in that way. 

So do you think this government will be able to hand down the right amount of autonomy and control for local systems to really deliver on this agenda? And if so, how best for them to do that?

Chris Thomas

Yeah, lots of people will have been listening will have been burnt before, right? More devolution, more autonomy at a place or a system or a local level has been a feature of the kind of rhetoric of reform plans for a long time across different governments and hasn't always actually followed through. So I totally agree. 

There are some indications for me that this time may be different. And the proof is always in the pudding. But the fact that the mayors have been very heavily involved in the new government's thinking and there seem to be some kind of formal mechanisms for that involvement seems to be very encouraging. 

Obviously not everywhere has a mayor, but often mayors can provide the test bed for kind of the devolution process that then gets spread elsewhere, so I think that is encouraging. The other one is that my understanding of mission working and I think the kind of latest waves that the mission working is being thought about genuinely demands the kind of devolution and empowerment of others that we're talking about. 

The best mission thinking, where people like Marion and Mazzucato are at the moment, is that it has to be driven by bottom-up solutions, bottom-up innovation, and that's the difference between kind of modern mission theory and the kind of missions that put a man on the moon, you know, kind of NASA going it alone. 

And if the government are really serious, which all indications are, about embedding missions as a way of doing government, then they'll need to make sure that devolution is a critical part of how they do that and that others have the resources, the capacity, the permission, the ideas they need to contribute to that bottom-up as I say. 

So we will obviously, I'm sure the NHS Confederation be strongly holding the kind of accountability on that and looking to make sure it does happen. But I think there are some good indications that it will or that there are plans to do so and we hope to see that very important that it does and that that has follow through.

Daniel Reynolds

Yeah, I agree. And certainly ahead of the government's new ten-year strategy on health that we'll be contributing to that certainly going to be a strong message that we'll be pushing to really empower local areas and systems to take this forward. 

So I think that's a great way to conclude the interview. Thanks ever so much, Chris, for coming on to help on the line. 

As I say, listeners can access the report on our website. So please do read it when you can.

That's it from me for now. So over to Matthew Taylor for his interview with Paul Mears. Thank you.

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Matthew Taylor

We're now two years on from the formal establishment of integrated care systems in England. ICSs, which are partnerships bringing together health and other organisations in local areas, were born into a challenging context. 

It's fair to say it's been far from plain sailing since. Political and economic uncertainty, hefty reductions to running cost allowances, rising inflation, cost-of-living crisis, industrial action. All of these factors have created a set of challenging circumstances. 

But many ICSs are now starting to flourish. For the NHS in the devolved nations, structural integration of this kind is however not new. So with ICSs at a crucial stage in their development, I wanted in this episode of Health On The Line to take soundings from someone further along the integration journey to see what more the English system can learn.

So for this discussion, I'm delighted to be joined by Paul Mears. Paul is chief executive of Cwm Taf Morgannwg Health Board in Wales and was previously chief executive of Yeovil District Hospital in Somerset. Paul's a longstanding integrated care enthusiast and advocate and innovator. He is well known for establishing the symphony programme while CEO at Yeovil. 

That programme is a primary and acute care system vanguard, integrated care across primary care at the acute hospital and community services. And it also prompted the establishment of Symphony Healthcare Services, a primary care subsidiary company of Yeovil District Hospital, which operates 12 practices within South Somerset. In fact, I visited Symphony just the other week. 

Paul started his NHS career in Torbay, where he was instrumental in setting up Torbay Care Trust and leading the operational business of one of the first integrated community health and social care organisations in England, as well as working as Chief Operating Officer at Torbay Hospital. 

Equally passionate about innovation, Paul is the national chief executive lead for innovation in the Welsh NHS. And he also leads the delivery of value-based healthcare across the country and sits on the management committee of the Welsh NHS Confederation.

Paul, welcome to Health on the Line. 

Paul Mears

Hello Matthew, nice to be here.

Matthew Taylor

How are things with you at the moment? 

Paul Mears

Well, like everybody, wrestling with some significant challenges, waiting to see what the future change of UK government brings, and obviously particularly interesting for us, whilst health has evolved in Wales, it's interesting to understand what any potential change of colour of government in UK Government might bring in terms of the interfacing with the Welsh Labour Government. 

So, lots of uncertainties in the macro system around us, but some interesting and innovative things going on in my own organisation. So despite those challenges, I'm very optimistic at the minute.

Matthew Taylor

That's good to hear. 

So, Paul, there can be very few people who have thought more about and practised more in the area of integration. So I want us to get right down to kind of the basics here. 

What do you understand by the concept of integration? And what is it fundamentally that we're trying to achieve when we talk about it? 

Paul Mears

So that's really interesting starting from, because I think the first thing to say is what integration isn't and it isn't in my new organisation structures and processes. I think that that's an enabler to providing good integrated care. But actually the most important thing is that you are enabled to bring together the right professionals to support the people in our communities when they most need our services and that we try to bring together the right interfaces for those individuals. 

And I think to me, throughout my career and invention, there are a number of the areas I've worked in over the years where innovation has been sort of an underpinning philosophy of what we've done, it's more about an ethos, a mindset, an approach supported where necessary by structure, but not designed in structure. 

And I think that's a really interesting, important point to make, particularly in the context of some of the things that have gone on in ways. And it's not just having structure of integrated services that brings everything together in one place that delivers better integrated care for the individual. It's actually an ethos and philosophy that underpins all of the critical behaviours and processes. 

For me, that's the most important thing, which drives better care for the population. 

Matthew Taylor

And what's at the heart of that philosophy? And I'll share with you, Paul, something that I said, it's a rather pompous thing to do, afraid, but I've reached the age where pomposity comes naturally to me. I'm going to quote myself. In my Confed Expo speech a few weeks ago, I talked about the concept of flow. And I said that I thought it was intriguing that we talk a lot about the notion of flow in the health service, because it betrays something. Because when we talk about flow, we mean the way patients flow around the kind of fixed banks and rocks of the health service. And that it's interesting because really shouldn't our ambition be that services flow around the needs of individuals? 

So is the heart of the philosophy of integration the idea that services need to be built around the needs of people rather than people having to navigate their way, themselves around the organisational architecture? 

Paul Mears

Yeah, I absolutely agree with you. 

I think the NHS has a preoccupation with organisational design being the answer to problems. And, as you might say, and it is very much underpinned with the work I did in Somerset, actually, was to say a one-size-fits-all NHS won't work for everyone, right? So there will be some people who need a very straightforward, simple service because they've just got an individual issue, transactional sort of relationship with a professional that just would sort and they can go out and deal with it. Integration is not needed for every patient. 

Where people need integration is where perhaps they've got a complex need, or they've got a pathway that means a number of people to be involved in that process. And we need to try and make, as you say, a process that underpins that care as streamlined as possible around the needs of the individual. 

And that could be a 55-year-old man dealing with prostate cancer needing to have really good care coordination of all the various stages of his treatment journey. Or it could be the frail elderly lady who's in their 90s with multiple co-morbidities living in a very precarious home situation who needs a very vast array of services supporting that in her own home. 

I think when talking about integrated care, think it's straight away we're interfering with elderly conversation. And of course, there's a very great deal of that need by fair elders. But there are also a lot of younger adults who need integrated care. I did my work in Somerset, we were quite surprised at the number of people who are under 65, who had high needs, who high users of health and care services, because they were complex diabetics, they might have had an alcohol problem, all sorts of people. 

So, integrated care is, as you say, it's a range of services that fit around the individual needs of the population, but are designed to meet particular segments of our population. I think for me, that's been one of the things I have learned over the years is trying to design a one-size-fits-all model really won't work. 

If you think about any other industry, what do you do? You segment your market, you design products to meet the markets that you're trying to serve. You design service models for those populations, you have different interactions and communication methods for those different populations of client or customer groups. 

Historically, we've had a relatively one-size-fits-all model of care that has been deployed. So for me, that's very much underpinning, as you described, what we should be doing is designing a service model to that individual needs population. 

Matthew Taylor

So Paul, why is it? No, I was going to say, why is it so difficult? But I'm going to be harsher than that. Why are we so bad at it? 

Our patient group has changed dramatically, hasn't it, over the last 30 years? 

I did a Channel 4 news conversation recently about, there's a dispatches expose of very bad treatment in an A&E hospital in Shrewsbury. And watching the programme, the thing that really hit me about the programme was on the one hand, the complexity of the needs of people coming into the A&E department. Thirty years ago, I think three quarters of people who went to A&E departments went with an injury. And now roughly that proportion are going with the flare ups of long-term conditions. 

So one thing that hits you is how more complex that is. Dealing with somebody who's got dementia as well as other conditions is so much more difficult and complex than, I don't know, repairing a sprained wrist or something. 

On the other hand, so many of those people who were there didn't look as though they really needed to be. I don't mean that in the sense that their needs were trivial; they had got to an emergency point. But you felt that so many of those people didn't need it to have got to that point had we built care more effectively around them, had we been more proactive, had they been given the kind of continuity of care that they needed. 

So it often feels to me as though the demand that we're meeting in health service has fundamentally changed over the last 30 years, but the way in which we deliver healthcare is still quite a long way behind. 

Paul Mears 

No, no, I agree. I think your example there is really good. So, we talk about one-size-fits-all model in the urgent care world. I mean, we have a one-size-fits-all model in A&E, don't we? Basically you could have anybody from having a serious cardiac event or a stroke or a major head injury, trauma, whatever, right through to someone who's got a finger that's a bit iffy. My perspective on that is I think we haven't designed the out-of-hospital care system effectively enough to divert people away from the front door. I talk to the clinicians in my hospitals and they would say 30 to 40 per cent of what actually they see in an ED really needs only ED commissions. You know, the rest of it could be dealt with in a different way by other professionals or other specialties. 

Yet we have a model at the moment where you can't get a bundle of GP what’s the only place that's open 24/7 where you're going to get support will help is the ED department. So unless we can provide alternative models, we are always going to see it's actually increasing demand as people's and demands and expectations for instant answers to a problem are ever greater. 

I think we live in a world now, don't we, where people are used to being able to get anything at the touch of a phone. Within ten seconds, they get an answer to something. I've got a 23-year-old daughter, and she says, well, why do I have to wait ten days to get an appointment at my GP practice to see them about a dermatology issue? And, you know, we can't provide that responsive service that people need, so the answer at the moment is everyone rolls into the A&E department. 

So I think we haven't really stopped to think about the different segments of our population and what their particular needs are. I think the needs, for example, for our older people who deteriorate, where their co-morbidities exacerbated, get worse, they should not be going into a busy ED department. Well, ideally they should have been looked after in their own room as much as possible.

Could we be developing more community-based models for sort of short-stay interventions for older people needing IV antibiotics or a bit of a geriatric assessment that's needed to be done? Does that need to be done in a busy ED or a busy acute hospital? Probably not. It could be done in a different model. So we've not really disrupted the model of care. I think what we've done is incrementally add to historic models and historic design services. 

And I think my perspective on things like hospitals is I really think that we need to question what is a future model of hospital in the next 20, 30, 40 years with the demographic changes we're seeing, we can't just think that hospitals are going to become an ever increasing growing place where we just warehouse frankly for our older people at the expense of people who then really do need acute care. 

And I think we could have got to challenge ourselves and say, how could that look different? And the whole out-of-hospitals, basically, really, is still pretty underdeveloped in terms of alternatives to ED. We don't have services that run 15 hours a day, 18 rounds a day, seven days a week in community services and primary care that provide a really solid alternative to going into ED. 

I think we've to start thinking about it, because unless you've got those alternative provisions back to your early code, designed around the individual, the people would always default to the easiest thing, which is the phone 999, and off they go in an ambulance into a hospital and go through that really torturous journey that many of our frail old people at the moment are going through of then being stuck in some bedside, not being able to get home. 

I think I started my career in community services, so I've always had a bit of a passion for out of hospital and community care. And if we're honest, I just don't think community out-of-hospital space gets the airtime and priority. I think it's everywhere. It's not just in England. I think it's same thing in Wales. So I think for me that was it's got to be part of our focus at the moment and energy meeting for it.

Matthew Taylor

Yeah, it's interesting, Paul. I have exactly the same mind and indeed that's why we organised last year our first Health Beyond the Hospital conference, which we're doing again, I think next year, because we really thought it was important to bring together the various sectors, including the acute sector, to focus specifically on care out of hospitals. 

But I take your point, Paul, that you made earlier on about the fact that integration is around philosophy. It's around our commitment to care that's built around the needs of the individual. 

But one of the things that's fascinating about you is that you have operated and been an innovator in relation to a whole number of different institutional forms. And so I'm fascinated to hear, Paul, from you: What have you learnt on that journey? Have you come to the strong view that it's good for acute and community services to be in the same organisation or have you come to a view about how we get the primary secondary interface right? 

Or are there things about the system in Wales which you think we ought to learn from in England? There must be some institutional predispositions that you've developed over the years, Paul. 

Paul Mears

Absolutely. So, when I was in England, I spent a lot of my time navigating processes. So, the torturous processes you have to go through if you're an acute care chief, you've got to try to work with your community services provider to help get them to design things that you think are what's needed to get people out of hospital, for example. 

When I worked in Torbay in health and social care, working with local authorities to try and sort of come together and get social care to align with some of the priorities in NHS. And that's always a challenge, isn't it? Everybody experiences that challenge of trying to, you know, gently negotiate, carefully sort of construct conversations, it structures around in partnership working. And so often I think in the NHS that's built on individuals.

So frankly, where success has happened, I think historically it's been driven by individual people who've led organisations or led programmes. Candidly, when they leave, often that process falls away. Even if you've created an organisational structure, right, it can often be the case that something that all melts away. So there is something in my head I've learned all the way about leadership, sustainability of things beyond one person. I think that's a really important thing, but it can't be about one person and when they leave, it disappears.

When I got approached about this role in Wales, I have to say that I looked at it and there was a bit of me, was a bit, well, the Welsh system was not necessarily where it needs to be in terms of priorities and performance. But equally, the one thing that really did attract me was the fact that the structures in Wales are, as you know, completely integrated. 

So as the chief executive of the health board, have acute health services, community services, mental health services, public health services and all the commissioning responsibilities for primary care, in its broadest sense. So then dental, optometry, pharmacy and primary care. So all the levers effectively. For me in a way it's the nirvana, right? It's all the things I've always wanted to do all in one place and the ability to make the best decisions for your population. 

So I’m really excited and that's what excited me about going into that opportunity. I think what it has struck me though, and it shows, the systems in Wales have been like this since 2009, is have we really exploited the opportunities that having all those teams in one place brings? Probably not, if I'm honest. I think because the organisations are such big scale operations, so my organisations went through a big impact organisation, 14,000 staff, 40 odd sites across a geography. So it's a big beast of an organisation to oversee and lead.

But I don't think we necessarily maximise those potential opportunities. It's not just about having everything in one place that makes it suddenly integrated, right? It's about how you drive and bring together those communities and also set an expectation of how you want to do it. And I think historically people are quite used to working in silos, aren't they? You if you're somebody managing a primary care practice, you're pretty much flat out day to day running GP practice. And yeah, you can see that there's things that need to change around you. But actually you've got the capacity to really step out of your day job and get involved in that and start to think about how you shift the balance of power, if you like, between primary and secondary care. 

Likewise, if you're a busy ED consultant and you see all the stuff coming through your front door and you know that really probably shouldn't be coming in? You probably don't feel it's got the influence of how you can shape and change the world. 

So one of the things I feel that I've done to my career is try and get those clinical teams alongside the clinical teams, talk to them about not working well and seeing my job as the person who tries to create the environment in which they can then come together and make some of the changes they want to do. 

So when I started in Somerset, for example, pretty unusually, I think for chief exec, I went around every single GP practice in my patch and met all the GPs and spoke to them individually about what they thought the issue was with the hospital. 

And frankly, you go through all the usual, well, the discharge and rooms of rubbish and you send out these people who don't need this, that and the other. And you ask, yes, people. And I said, right, okay, I'll take that. We'll deal with all that operation stuff. But once we've dealt with that, what could we do to build the relationship between primary care and second care? Cause you're all telling me that these people don't need to be in hospital. So what are we going to do differently together to work on that? So that's where the Symphony programme was really evolved from. 

So I do honestly think that a lot of this comes down to leadership and it comes down to vision and a willingness to challenge the norms because I think we work in a world where, you know, if you're in a kiosk, which you exactly your job is to run the kiosk, that's what you're managed on. That's what you're incentivised on. That's what your performance managed on. 

I think ICS are bringing people much more into the wider integration space. And there's a more of a collective responsibility. But let's be honest, if you're a big, large FT working in an ICS and then someone's going to tell you, going to have to shift all this work out and your ambition to have a nice, brand new, big, shiny hospital might not be quite as valid as it once was a few years ago. Are you going to say, yeah, that sounds like a great idea? And people might say they would, but in reality is that actually going to change. So I think maybe it's that ethos, it's that vision, it's the leadership, but it's also the willingness towards to seed some element of control to things. 

That's difficult for leaders often to say, okay, I'll give that up and hand that over to someone else to take responsibility for because they're probably better placed than I am to run that. And I think that is a really difficult thing. I think people haven't gotten into these jobs historically from just being passive. My view is if you get to be a chief exec, you're probably quite a competitive person who wants to be successful. And we’re then surprised when we put a group of chief executive in a room and expect them to suddenly all work together and collaborate and perform, and agree that the collective benefits is greater than the individual benefits. 

I'm perhaps being a bit harsh there, but I think in this about leadership, and that it’s fundamental at every level, chief executive level, clinical leadership level, ward manager level, GP practice manager level, it's all about people being aligned towards the same common purpose and challenging each other about where they feel those barriers are happening that prevents them from doing what they want to do.

Matthew Taylor

Yes, so Paul, I completely agree. And I think that this is something that I come to again and again in these kinds of conversations, which is we talk about all sorts of things and then we come back to leadership. The problem is that then leadership starts to feel like a kind of black box. It feels like it boils down to this thing, but it's a thing which is hard to understand. Where does leadership come from? How do you summon it up if it isn't there? 

I think that we don't sufficiently recognise the vital importance of putting the time in to build a culture of leadership. I think we know quite a lot about organisational leadership. I'm not sure we always get it right. I think sometimes we can be a bit mechanical when we think about it. But we know much less about system leadership. 

The Confed puts together a system improvement programme with Q network at the Health Foundation. And part of the reason we've done that is because we think that leadership in system, in place, collaborative leadership, leadership necessary for integration does involve a different kind of set of skills. And I think trying to get into that black box so that we don't simply say, well, it's down to leadership and trust. And people go, well, great, but where is this leadership and trust? Where do I buy it from? You know, we have to do the hard work of saying, actually there are ways in which you do this. So for example, I've come to this kind of, it's very trite, I'm afraid, but this kind of journey that I think sectors within the health service locally need to go through, which is from irritation to integration to innovation. 

So let me explain briefly that, you go to anywhere and the first thing you'll hear when you talk to the acute is how they feel let down by primary or by social care or by the ICS or whatever. When you talk to the ambulances, they'll talk about how the terrible things that emergency departments do to them. I'm afraid blame is really very high up our narrative in the NHS in a way which is actually slightly unusual. If you go to leaders in other sectors, blaming other people is not really considered to be a very strong, a very good leadership trait. But, you know, we turn to it pretty quickly in the NHS. 

So first of all, You've got to go through that pain. You know, we're doing some work in the Confed about the primary secondary interface. You just got to start off by saying, okay, look, come on. How are we really annoying each other, irritating each other? Let's put that on the table. And then if you do the work there, generally you will find that actually there are relatively straightforward ways of overcoming those irritations. 

Then the next step is to say, okay, what can we do to kind of bring things together a bit better? The ideas we've been talking about Paul, which is let's just try to streamline things a bit better. Let's try to make things lock together a little bit better. 

And then the final bit, the kind of transcendent bit is when you go, well, actually now we stopped annoying each other. Now we've started kind of getting things aligned, suddenly the possibility of doing things differently occurs. 

Now, the point I want to make here, Paul, and sorry, I'm going on at such length is you can't get to the innovation piece unless you do the hard work of getting through the irritation piece. So you get a group of people in the room who know each other day-to-day and say, how are going to do things differently? It's a complete and utter waste of time. 

Paul Mears

Yeah, yeah, I agree. I agree. Absolutely. And it goes back to my point about what innovation is not. It's not an organisation structure. Because if you think by bolting bits of a frankly dysfunctional or irritated systems together, it's suddenly going to be a magic wand that's going to suddenly make everybody say, great, we'll all work together now because we've worked under this integrated system. It’s not going to work. 

I absolutely agree with your sort of three levels that until you sort out the day-to-day stuff that is getting in the way of people working together, you won't be able to move on to an integration journey. 

I remember back to my days working in Torbay when we working together health and social care, historically massive discord with people saying, if only social services would do this, we'd get everyone out hospital quicker and they’d be saying, if only health wasn't sort of thinking everybody needed a medical model of seeing when actually it's all about social, the social models. And actually until you get those people together and talking about it.

I remember one of the things we did when we did that bit of work in Torbay was we had everyone in the room together. We had GPs, social workers, engineers, everyone. And we said, right, okay, so take a scenario that GP has identified an [xxx] need.

And we literally lined up the number of people that would be required to get that package of care set up in the road. The GP at one end would see the need and the don care manager or worker at the other end who was supposed to have 12 people we calculated were needed. And we said, right, our ambition is to shrink that so that the GP could speak to one person, describe the issue and the care is set up. And that's what we got to.

All those steps in their 12-people journey were irritations that people had – to refer someone on, they didn't meet the criteria so they got bounced onto somebody else, and all that stuff is what really, really bugs clinical professionals because they can see what needs to happen for the individual, but we've put in this bureaucratic process around them that said, well, if it's a Wednesday and it's half past three, that person can't be seen by nurse X because they don't do that. Or sorry, you don't meet the criteria for this service, you'll have to phone this number. And it's not just frustrating for the professionals - or if you think it's that frustrating for the professional, imagine how frustrating it is for the patient and their family who are then trying to navigate their way through that system and not knowing who they go to or who to speak to. 

So you're absolutely right. Until you sort some of the day-to-day stuff that is bothering people, you're not then going to get them together to think about, actually what you do strategically to redesign this system to make it more efficient, more patient-centred. And then as you rightly say, and once you start to get those people working together and then shared objectives, shared ambition, shared understanding of what they're trying to do, suddenly they start saying, you know what, we could probably do that really differently or innovate. Why are we even doing that process in the first place manually? Let's bring in a digital solution that enables us to do that differently. Let's, I don't know, do something here, redesign the service completely from top to bottom, but they've got a shared understanding, they know each other, they understand each other. You know, cycling, the biggest impact that it led in Torbay was bringing them in the same room together and sitting them in an office together. You had social workers, nurses, physios, OTs, all in one big space in a locality, and their job was to run and look after that population of people. 

And hey presto, suddenly social workers said, I didn't know you were dealing with this, Dr Jones, I just said, you talking about that? And they'd suddenly have a conversation. So, well, actually, if you're going out this afternoon, I don't need to bother going because could you just take that walking aid that she needs rather than sending out the OT a bit? And it was unbelievable just how some of those simple basic stuff that bring people to try and overthink this, right? We over, we over-specify, we over-design it. 

And actually, this is about just people working together doing the right thing for the population. And our job as leaders, surely, is to create the architecture around them that enables that to happen. Whether it's physical architecture, whether it's digital infrastructure, whether it's governance structures and safe working processes or HR policies, whatever. But I think we get so preoccupied with the design of this thing, we don't pay attention to all that other stuff that is so, so important on a day-to-day basis. 

Matthew Taylor

Yeah, absolutely, Paul. And I think that part of this is also about recognising that the barriers we're requiring people to overcome are big barriers. You know, I think sometimes we talk about failure to integrate as if, why are we not doing this really obvious and simple thing, but actually the logic of organisations, you know, so if you're a patient, the world is made up of organisations with porous boundaries because you're going from one organisation to another organisation. 

But if you run an organisation, there are the things you control and then there's hard walls beyond that that things that you don't control. So the way we work in organisations gives us a picture of the world, which is very different to the kind of principles of integration. 

You've then got professional defensiveness and professional boundaries, particularly an issue amongst clinicians. We did have in England in particular that competitive mindset, which didn't help us at all. Organisational leaders, I'm very competitive, organisational leaders are competitive. So when you have a government that encourages even more of that, now I'd say I think we suffer from a scarcity mindset.

And I think when there's this feeling of inadequacy and scarcity and we can't achieve what we want to achieve, then can blame defensiveness, risk aversion, all these things come to the forefront. 

So I think when we work with our colleagues around these challenges, we have to acknowledge we're asked them to do something pretty difficult, but if we don't do it, we're never gonna get out of the place we are. 

Now, Paul, I don't wanna wind up without asking you about innovation. we've almost run out of time, so I've not got this interview right. I have to get you back on Health on the Line, but innovation has been a key part of your career. Let's just end by, can you pick something that you're doing in Wales at the moment, which is innovative and that you're particularly excited by? I'd love to hear an example from you. 

Paul Mears

One of the things we are doing, which I think is, so we've got a really good structure now in our health board where we have what we call the navigation hub. It's run by GPs and other professionals in the community, supports the out-of-hours GP service, so out of hours, but in hours is also available to support admission affordances. So we've got GP, we've now added to that team with OT, paramedics, nurses, and going back to my earlier point about how do we design a better model of out-of-hospital care, I'm really excited to think about how that model could start to be expanded into looking at urgent on the day primary care demand. 

We talked to nursing homes about whether they that sort of navigation hub becomes their first port of call for any problems or concerns they've got about an individual in their care to avoid confirming 999 and sending the person from hospital. There's a whole heap of work we can do with advanced care planning to make sure that those patients in our communities who don't need to be taken to hospital have got that clean discarding written in. 

So it doesn't sound super exciting or super innovative, probably, to many people listening, because you've probably got that in other parts of the UK, but in our patch we have never had anything like that. And it's beginning to have some really positive impact on a lot of our population in our communities to avoid them being taken to hospital, so that's something for me, which is really exciting. 

And then underpinning that also is the work with the rural population health management in our patch. Because we have public health in the health branch, is really positive, we've got a single data set now that identifies and segments our whole population which enables us then also start to have these things like a navigation, say proactive care coordination centre to actually contact proactively those patients that are the most risky segments of our population to try and avoid them deteriorating further, picking up on the issues early doors, intervening earlier to try and avoid situation. 

So I guess it's a piece of work around the whole management of our population, which for a population, we know often is a very deprived population relations and the worst outcomes anywhere in the UK, it feels really, really important to do. So that for me is a really exciting, innovative piece of work that I think has some good potential to really make an impact in our communities. 

Matthew Taylor

Which leads to a very, very final question, Paul. And again, I have to ask you to be reasonably concise about this, data, digital, what is its potential in relation to accelerating some of the things that we've been talking about in terms of particularly better integration built around individuals.

Paul Mears 

So to come back to my earlier point, Matthew, about if we want to segment our population and design services around the population, we've got to know what's the population we're actually talking about. And the only way you can understand that is by looking at the data and what does that tell you? And that's data that brings together primary care, community services, ambulance data, hospital data, prescribing data. That's exactly what our Symphony dataset did in Somerset. 

And it was the data that drove the design of the care models that designed the model of integration that we implemented in Somerset. And I think if you try and do this without data to help design the model, you basically can be doing it on the back of individual people perspectives or opinions, which I’m not saying you're wrong, but in any other industry, the first thing you do would be to look at what's the data telling us and what do we need to do to use the data to design the way we deliver says. 

And also, how do we use the data then more change something to measure the impact it's had and understand if it's to limit certain things that we want to do because what we're probably pretty terrible at in the NHS is actually evaluating did the thing we implement actually have the impact and said it was and if it hasn't had the impact we should stop it and refine it and redesign it and I just don't think we use data and information to drive how we design and we shape and refine our services. We tend to do a whole heap of work, get excited about it, it might have some good impact, it might not, and then we move on to the next thing. That's the latest initiative that's come down, or the latest that asked that's come to us from somebody else. And I've got to get much more robust at using data and information to drive everything we do, personally and naturally.

Matthew Taylor

Well, Paul, I've been looking forward to this conversation and it's absolutely lived up to my hopes and expectations. Thank you so much for joining me on Health on the Line. 

Paul Mears

Thanks very much, Matthew.

Matthew Taylor

And thank you all for listening. This episode of Health on the Line has been supported by Novartis. If you enjoy Health on the Line, why don't you leave a rating or a review in wherever it is you get your podcasts. It really does make a difference. But until next time, goodbye.