Patricia Hewitt: Influencing the way ICSs work and how the centre works with them

Matthew

Hello and welcome to a special edition of Health on the Line, featuring a conversation I held recently with Patricia Hewitt, who is, of course, leading a review of accountability and regulation in the health service with particular reference to system working. But as I speak, industrial action, in the NHS is continuing to widen and deepen, with many leaders now facing combined action on February the 6th. We seem stuck in a war of attrition where the ability of the NHS to cope day to day is masking the deeper impact that disruption is having. As I've been saying in the media, NHS leaders face the incredibly challenging task of meeting high levels of demand, while at the same time making inroads into the treatment backlog, which exists in all parts of the system.

Of course, these two issues are related, as it’s higher levels of untreated sickness in the community that partly drives greater urgent and emergency demand. The NHS is doing all it can to break out of that vicious circle. But the industrial action makes that task much, much harder, something that Amanda Pritchard has recently acknowledged. We at the Confed will continue to press both sides to be pragmatic and creative in finding a solution. Regular strike days cannot become business as usual. And if junior doctor strikes are added to the nurses and ambulance staff, it's difficult to see how performance will not fall further from where we want it to be.

And winter pressures remain, as we saw from last week's figures from NHS England, with less than 5 per cent of beds free currently, something that is not helped by over 14,000 beds still being taken up by patients who don't need to be in hospital anymore but can't leave due to capacity problems elsewhere. Health leaders are doing their best to use the emergency funding that's been released. But we can't help wishing that the government had listened to our advice and awarded and dispersed this investment several months ago. If they had done, it would have been easier to use that money effectively.

There's also concern, I've heard amongst members, at the new fund to create more short-term places in care homes. The danger is that once the funding stops for these places, patients will be stuck again without the right community offer. Some systems and places are trying to ensure that the offer includes reablement, but again, this is having to be done at the last minute and with the usual staffing constraints.

On a more positive note, our Mental Health Trust members welcome the allocation of funding, which was first announced in 2021, to ensure that patients are cared for in appropriate settings. With record demand for services, an increasing number of people reaching mental health crisis, it's important that there's a focus on finding ways to provide a more therapeutic environment for those who need this kind of support.

In other news, this week, we've also published our latest long read around the cost-of-living crisis. This one concentrates particularly on mental health. It's entitled Can Mental Health Services Afford the Cost-of-Living Crisis? The post recognises that rising prices are exacerbating already overstretched mental health services and increasing mental health pressures on all ages across the population.

In the long term, surely the only way we can break out of the vicious circle of deteriorating population health and growing demand is to embrace a fully integrated way of working across the whole of health and social care, and including the voluntary sector, local authority and other partners. And that, of course, is a large part of why integrated care systems, ICSs, came into being. All of which brings me back to my conversation with Patricia, a conversation in which we explore how the oversight and governance of ICSs can best enable them to succeed and build healthier communities.

Matthew

So, I'm delighted to be joined by Patricia Hewitt, who I've known for some time, but now working with through the Confed in supporting a very important review that she's been asked to undertake, looking at issues around governance, accountability, management within the NHS with a particular focus on how we ensure that our new system based way of working is successful. So, Patricia, welcome to Health on the Line.

Patricia

Thank you. It's lovely to be working with you, and Matthew thank you for all the help you're giving me with this review.

Matthew

I just want to start with just a little bit about you and in particular - I mean, I worked with you when I was working for Tony Blair, in Number 10, when you became Secretary of State for health, a very challenging time. And if there wasn't so much else to discuss, I could just spend hours talking to you about that. But I think I want to ask you something slightly more specific, which is you’re now chair of Norfolk and Waveney ICS, so, you're seeing things not exactly from the bottom up, but you're certainly a lot closer, as it were, to the front line. How has that impacted your perception of decision making within the NHS? That contrast with the lens of looking down from the top as Secretary of State and now looking up, as it were, from an ICS?

Patricia

Well, I wish I'd been able to do this or the equivalent before I became health secretary rather than afterwards. And I do remember as health secretary quite early on when we were discussing various changes that we thought needed to be made, and I said to my officials, hang on a second, do we need some legislation here? Do we need statutory instruments, something like that? They said, oh, no, Minister, no, no, no. The 19, whatever it was, of course, this was way before Lansley, they said, the act gives you all the power you need. You will simply write a letter to the service. And so, I was in this extraordinary situation where in theory, I had all this power, apparently, to issue requests or even instructions to the service. And of course, I very rapidly discovered that a lot of this was illusory, and that life was a great deal more complicated than you could see sitting at the top of the office.

Matthew

Yeah, I remember Stephen Coleman, who's an academic who writes a lot about democracy. He had this line I used to love, which he said the problem with democracy is hard-to-reach people and there are no harder to reach people than politicians.

And I guess what I got out from that is the way that things look when you're at the centre; it gives you a particular lens on the world, that in the centre you tend to look out and imagine that everywhere is kind of the same, that something that works in one place must be able to work everywhere else. And it's not that that's always wrong. It is just about if you're in the centre, understanding that you have a particular predisposition to see the world in a certain way and somehow to make adjustments for that.

Patricia

That is true, but only partly true, because remember that pretty much by definition, if you were a cabinet minister in our system, you're also a constituency member of parliament. So, I learnt a lot actually about the health service through my constituents, clinicians, talking to managers, visiting hospitals, going out, going to see local primary care centres and, and, and.

So, I also had that bottom-up perspective. But of course, it was a perspective. I was a member of parliament in Leicester, so I had a lot of insight into life of very hard-pressed constituents in, you know, left behind council estates, for instance. But it can mislead you. For instance, one of the first things I had to deal with and ran into a lot of problems with, I inherited a manifesto commitment to cut administrative costs and put the money into frontline care. Very standard stuff. What I discovered when I became health secretary was the route to that particular manifesto commitment, which was very precise, was slashing the number of primary care trusts.

And because in Leicester, in the city of Leicester, the primary care trusts had been really struggling to fill vacancies and increasingly were working with a single management team, it all looked perfectly sensible. But of course, it was a very different picture in some other parts of the country, and particularly in large rural geographies like Norfolk and Waveney, where I now am.

So, you can be misled sometimes, although as I say, that bottom-up perspective from the people you serve is really important as a minister. But I think the temptation to think, oh my God, there's something brilliant going on in my constituency or some other place I visited or this hospital's cracked it or whatever. Right. We'll just instruct everybody to do the same. And given the pressure that you are under as a health secretary, well, now, of course, Secretary of State for Health and Social Care, to be seen, to be acting and delivering, that temptation to act and to pull levers is a great temptation. Even if it's not always the right answer.

Matthew

Yes. And we've seen that, of course, in recent weeks where we've had the creation of new national funding streams at very short notice to deal with a national crisis which are causing quite a lot of difficulties in terms of, on the one hand, very onerous reporting requirements for what are relatively small pots of money in comparison to the overall NHS budget. And also, how do you spend this money effectively in such short order?

I know that in some of the kind of responses to your review so far, both these issues, this kind of small packets of money which are over prescribed, but also needing to do things in very short kind of timescales rather than thinking about the kinds of issues that people raise. So, let's turn to the review, because this is what the review is in part about.

Just tell me first, Patricia, how were you approached to do the review and were you clear from the very beginning this is something you wanted to do?

Patricia

Well, I was. It was mentioned to me by the chancellor, and I was then asked to do it by Steve Barclay, by the Secretary of State for Health and Social Care. And I just felt this was such an opportunity to help influence the way in which integrated care systems work and the way the centre works with them. And I absolutely believe in integrated care systems, in a sense they have many, many origins. But one of their origins is Our Health, Our Care, Our Say, which was this huge public consultation that I led when I was Secretary of State for health, which Simon Stevens always said was part of the inspiration for the long-term plan. So, I believe in integrated care systems, and I just felt doing this review was a way in which I could support, not just my own integrated care system, but system working, these critical local partnerships all across the country. So, I said yes immediately.

Matthew

And in the six weeks or so since you took on the responsibility for the review, and challengingly that means you are kind of a third away through the time, the overall time you've got for it. How was your, we're going to come in a moment to the principles that you've outlined and some of the workstreams that you're asking colleagues to focus on, but has your thinking changed since you were first asked to do this? And also, how are you now thinking about where you want to end up, what you're hoping to get to by the end of the process?

Patricia

My thinking has changed, and I mean for me, and I hope for many others, part of the importance of a review like this is how much you learn through the process of doing it.

By Christmas I'd spoken to over 300 leaders from systems around the country and from national organisations. That must be a lot closer to 400. And there are around 400 submissions of evidence that have come in already which interweave with sifting through and learning from.

But I think the critical thing when this review started, the problem was very much seen almost by everybody as integrated care systems. Good. Tick. That's exactly what we need. The problem is too much micromanagement from the centre, too many priorities, too many targets, and so on and so forth.

Actually, what emerged quite quickly in those early conversations was we all need to change because fundamentally integrated care systems are a fundamental shift in the organising principle from competition and choice as the organising principle for the NHS, which it was for 30/35 years, under governments of pretty much all political complexions to an organising principle of collaboration, not simply within the National Health Service, but crucially between the NHS, local government, the voluntary sector, social care providers, mainly, of course small and medium sized enterprises who between them employ more people even than the NHS itself. Those and other statutory bodies and other employers and so on. They are all partners and stakeholders in each of the 42 local integrated care systems.

And we all need to change the way we work. For instance, I've had acute hospital trusts saying they're still getting quite old-fashioned transactional commissioning style behaviour from their integrated care boards, not the leaders really, but further down. Not surprisingly. These are new organisations.

I've had integrated care systems saying in some cases they've got large teaching hospitals or other acute, in particular, who don't want to play ball with the integrated care board and just regard them as just another version of the CCG and they're not very interested.

So, all of us learning how to work in this collaborative way where we are all sitting around the table owning the problem together. And that includes the very immediate problems, which show up with the ambulance handovers, which are fundamentally problems about not giving older people, especially, the care and support they need in primary, community, social care, and in the community, which keeps them out of hospital wherever possible, and if they are in hospital, ensures that they can leave hospital as soon as they are medically ready to do so, because those are the fundamental issues which are showing up in the current horrors of what is happening in an NHS under unprecedented levels of pressure.

Matthew

And that takes me to the principles that you've outlined in your interim response. I mean, you were given a ludicrously short amount of time, but in that time, you developed this kind of set of principles.

Now you've talked about the first one of those principles, which is collaboration, and I think you've been very clear about wanting to move away from a kind of when we think about the NHS, we think about a triangle and you instead want us to think about, as it were, overlapping circles. And yes, the centre may be the central circle, the biggest circle, but yet it is a matter of overlapping circles, of collaborative circles rather than the single kind of pointy hierarchy.

Let's pick a couple of the other kind of principles and explore what your thinking is with them. So you talk about balancing freedom with accountability and you said in a recent HSJ interview that actually some systems might need more support and oversight rather than less in this development stage that they're in. What's your thinking around this notion of balancing freedom and accountability? And how strong is the sense that this will vary depending upon the success, the development of systems, that kind of notion of earned autonomy or sometimes presumed autonomy, it's called.

Patricia

This is really the absolutely central issue for this review and very clearly spelt out in the in the terms of reference.

I very much like the idea of presumed autonomy. NHS England used to talk a lot about system by default, and I think that's a really important principle in all of this.

But again, what I know just from talking to colleagues over many years now in different systems, we're all different, I like Chris Ham's idea, when you've seen one, ICS you've seen one, ICS. So, we're all different. And some of that is to do with geography and the state of relationships and the size, and urban versus large rural geographies, and so on.

But we're also different in the state of maturity and the state of relationships between different leaders. And the point that I was making, perhaps slightly clumsily with the HSJ, I used the phrase some systems will need more ‘control’ than others, and I think ‘support’ would have been a more accurate reflection of my views. But there are undoubtedly systems, and NHS partnerships in particular, that really struggle to solve problems together and to get the best possible outcomes within their budget.

And as well as being a former health secretary, I'm also a former treasury minister and I'm very well aware, given the roughly £200 billion investment in the NHS from taxpayers and the pressing need for social care amongst other parts of our wider social system, pressing need for social care to have more investment. We have to make sure we really get the best possible value for what will always be a finite amount of money.

Some more mature integrated care systems and boards can get on with doing that very well themselves. But they need time and space and not the kinds of last-minute small pots of money, excessive rules, excessive demands for data and so on get in the way and have done for many years. That, I think, is very helpfully recognised in the latest planning guidance. But there are a smaller number of systems where the ICB is going to need a great deal more support and guidance, amongst other things, just to make sure that the deficit doesn't get out of control.

Matthew

So, one of the things I think you wanted to emphasise is that and you’ve already said this in our conversation, Patricia, is that this is not, as it were, just about the relationship between system and the centre, but it's also about the relationships of accountability within systems.

I talk to system leaders and provider leaders all the time and often what they describe is a perplexing complexity in relation to accountability within the system.

So, you have the system, you often have places within the system coterminous with local authorities, and even that's quite complex, you know, there’s a system I can think of, for example, where one half of the system is got a single place with a single upper tier authority. The other half of the place has got district councils and an upper tier authority. So even that's kind of quite complicated. You've got place then you've got providers and provider collaboratives, and provider collaboratives themselves are at an early stage of evolution there’s some work we've just done around collaboratives, around their growth. But, but they, like systems, will say that they are in the kind of stage of forming and starting to develop, not yet fully collaborating.

How, how ambitious are you for the idea that your review can help people to understand a bit more clearly how these different constituent parts can most effectively function locally, given that they vary from the kind of north east where you've got an enormous number of places to something like Gloucestershire, where it's a single place, a single acute trust, a single system.

Patricia

I think the review can help. As you've said, we're working to an incredibly tight timescale, but I think it's enabling us to bring together not just ICB and integrated care partnership leaders, but leaders, and leaders at many levels, from trusts, from local councils, from the voluntary sector, from social care providers to help think through these problems. And within the NHS itself, there is, I think, a real danger that people see integrated care boards, in particular, as just another point in a vertical command and control hierarchy with ministers and NHS England at the top and then the regions and then the ICBs and then the trusts, and… and… and.

And if that's the mental model or the policy design, it will be disastrous because you cannot run complex systems, complex adaptive systems, which is what an integrated care system is by instruction and command and control from the centre - and the NHS itself, which after all, within any one system consists of multiple primary care practices, pharmacies, opticians, dentists, all those parts of primary care, the community, the mental health, the acute trusts, the ICB itself, and then the partnership with social care, and, and, and. You can't even run that through command and control and instruction.

So, moving to a limited number of the priorities, targets that everybody understands are clear national shared priorities. We all get that. But giving the integrated care systems time to work out how this process of mutual accountability works within each system.

That is critical because integrated care systems didn't come into being on the 1st of July. We've been building them since the early days of STPs. That's five or six years ago. In some cases, typically the most successful ones, they've been building these partnerships and this collaboration for the last ten years and more. And I think as we spend the next six weeks or so, really in much more detailed conversations, we will all be learning from each other about how you distinguish between, for instance, an acute hospital foundation trust with its own board and its own statutory responsibilities, clearly responsible for the quality and safety and accessibility of what they are delivering inside their hospital, but they also remember have a statutory duty to collaborate, itself very new, only from the 1st of July.

Not that we are relying on that statutory duty, but building a partnership where this problem that is so immediately visible of people not getting the right care in the right place and therefore being stuck waiting for an ambulance, lying in an ambulance outside the hospital, waiting for a bed or stuck in the hospital at the other end, waiting for the right care package to get them out, that problem is owned collectively and it is clear within each system who has to do what by when in order to reduce those ambulance delays and start making the transformational change that will make next winter better than this winter.

Now that is something where the integrated care board and the wider partnership have a critical role as catalyst, but where you have to create a culture of that mutual responsibility, that ability to have honest, sometimes difficult conversations with each other, but not fall into the trap of, well, we are doing our bit, the problem is all to do with social care. or it's all to do with…, that, passing the blame to somebody else in the system when it we all have a part to play in this and we all need to be solving it together. That's the difficult bit and you can't simply instruct that to happen from the centre. Although I think the CQC as it develops into a mature inspector of systems can really help a system understand where it is in that journey.

Matthew

So, Patricia, I could speak with you for hours. It's absolutely fascinating. And the Confed is really enjoying working with you around the principles, around the kind of key workstreams. One of those workstreams is precisely as you've just been emphasising, of prevention and population health management. How does thinking differently about accountability enable us to achieve what we’ve failed to achieve for the last 20, more years than we've been talking about, which is that kind of leftward shift of resources upstream and more into prevention.

But I kind of want to end up with a with a kind of simple way of trying to capture this. And for you to tell me whether or not you think it's right and what's involved in it. So, this is a caricature, I know, but if you look at the health service, it often feels as though what happens at each level of the health service is that accountability is experienced as something which you owe to the people above you. So, you know, you are in a trust and you have accountability maybe to your system, your system, your accountability is your region of accountability at the centre. People are looking up and they owe accountability upwards.

Now, what we would like surely to achieve, and this is a cultural shift as much as anything, is to reverse that and say the accountability is accountability downwards, in the sense of ‘am I enabling those below me to be able to solve problems, to do what they need to do.’ And that if each tier, as it were, we don't really want to think in terms of tiers, but if each bit of the system thought the question I must ask myself is how am I accountable downwards? I am accountable, if I'm in NHS England, I'm accountable for where the systems feel that I am empowering and supporting them to solve problems. In a system, I am accountable downward for whether my provider collaboratives, my places, feel empowered and enable to solve problems together. So, is that do you think are kind of at the heart of what we need to try to do? And what do you see as being the kind of the challenge here? Because I think, for example, it is going to require a different kind of public sector leadership in the health service.

Patricia

I completely agree.

And some of us talk about inverting the triangle and serving. I mean, we are all doing what we do because we want to make a difference. We're all here within integrated care systems to serve local residents. Local government, of course, is directly accountable to those local residents through elections and people working at the frontline, whether it's in health or in social care, feel directly accountable in many, often very sharp, ways to their patients, but also through more formal mechanisms, governors and so on, patient and public groups and so on.

But this process of local accountability and judging ourselves, as in my case, the chair of an integrated care board, the deputy chair of our integrated care partnership, by whether or not I am enabling and empowering the people at the frontline who can really make a difference, and doing that, you know, through things like 360 degree reviews and stuff like that, that for me is absolutely critical.

And that applies, as you say, all the way, quote unquote, up the line. So that NHS England, which has, you know, the centre has critical functions here, not least to make sure that there's proper digital systems, interoperability and timely and good quality data so that everybody, whether it is patients, the public, local government, the CQC, NHS England itself, ministers, whoever wants to see what is happening can do so very easily and quickly through that transparent mechanism.

It's a very different way of thinking about it. And I think we're seeing in in different parts of the public sector and public services, we're seeing exactly that sense of a different kind of public service leadership. But we need to be building it collectively within integrated care systems, not just within the NHS.

Matthew

Yes, and I think it's been fascinating, Patricia, in some of the meetings that you've hosted that I've been in to, to hear different perspectives from ICS leaders.

And I think that's on the one hand, I think that's fine. But on the other hand, I think from the Confed’s point of view, challenging ICS leaders to have a really robust conversation about the kind of leadership that they want to provide, the kinds of accountability that they want to see. I think that's a really important part of this conversation, which actually your review has added focus on those questions, which is which is really valuable.

Patricia, thank you so much for spending this time with us. I hope that you will come back to Health on the Line very soon after you publish your final report.

Patricia

Well, I'd love to do that, Matthew. Thank you very much. It's always a pleasure talking to you.