Integrated care systems: one year on

Matthew Taylor

Hello. I'm speaking to you at the beginning of what we hope will be a really positive week for the health service. Tomorrow I'm going to Downing Street for a briefing on the new long-term workforce plan. My goodness, we've waited years and years for this, but it looks like it's finally going to be arriving. And from what we've seen in consultations that we've been involved in, in the plan, we can welcome the commitment to increasing university spaces, the greater use of alternative routes to practice, such as apprenticeships and the recognition of the importance of different roles such as physician associates, nursing associates and the role they can play in contributing to delivery of care.

So, we'll be looking very carefully at that plan. And if we think there are challenges with it, we'll say so. But we're hoping overwhelmingly to give it a very positive response. Of course, the irony is that this workforce plan will be set against the backdrop of continuing industrial action. We know now there are five days of junior doctor strikes planned. That's a real blow for us, for the service and for our capacity to meet the stretching targets that we've got. And as I speak to you, we're still waiting to find out about the RCN ballot and the consultant’s ballot.

So, the challenge here is we may have a long-term workforce plan, but there are some very challenging short- and medium-term issues that we still need to address, particularly, as I say, if we're going to meet those stretching targets that system and trust leaders have signed up to.

So, three people who've got their fingers on the pulse of these kinds of issues of how we deal with the challenges to our capacity - how we meet stretching targets - are the system leaders that I talked to at ConfedExpo a couple of weeks ago. Those system leaders are Amanda Sullivan, Kevin Lavery and Patrick Vernon, and they all joined me for a discussion on integrated care systems, just one year on from the establishment of ICSs as statutory bodies.

In the discussion you're about to hear, which I find absolutely fascinating, You'll hear about what's driven their success, what they've found most challenging, and what their ambitions are for the next year for integrated care systems.

Hello and welcome to Health On The Line, recorded at ConfedExpo 2023 in sunny Manchester. This is the morning of the second day of our annual conference. It's already been a really interesting event. We had a major speeches yesterday from Amanda Pritchard and from Wes Streeting and lots of activity, 4,500 people here today.

I've got three great guests to talk to for today's Health On The Line. We're going to mainly talk about integrated care systems because it's also just about a year since they were established. And that's the focus of our conversation. But I'm just going to kick off by introducing you to the folks who've joined me today on Health On The Line and just going to ask them how ConfedExpo has been for them so far?

So, Patrick, I'll start with you. You’re interim ICB chair for Birmingham and Solihull. What's been your highlights of ConfedExpo for you so far?

Patrick Vernon

Well, on the first I had the opportunity to chair a session on the role of the NHS and the anchor institution. It was actually well attended. There must have been over 100 people plus in the room, we had some fantastic panellists.

And what was quite clear from that session was we know that we've got the most to do, but people really want to get involved in tackling health inequalities, use the economic power of the NHS in a different way, and we just need to create that space and opportunity for ICSs, working in partnership with local authorities, the community, private sector and other providers just to create that opportunity.

I mean, we've got a ten-year strategy which is ambitious, and I think that's what we need to do. That's part of our job as well as doing the must-dos, which obviously we're constantly reminded by governments and everyone else.

Matthew Taylor

Yeah, that kind of fourth purpose of ICSs; economic, social, environmental impact is really interesting and it's an area that we think about a lot in the Confed so that thanks for that Patrick.

Kevin Lavery, ICB CEO, Lancashire and South Cumbria. Kevin, what's been your highlight so far?

Kevin Lavery

Thanks, Matthew. Well, first of all, it's my first Confed Expo. I was unable to come last year because we were setting up the ICB, which was about go live last year. So, it's been really good. I went to a lunchtime session after Amanda's speech, which was about technology and innovation, and saw a really interesting presentation on the use of drones in Northumberland.

Matthew Taylor

Oh really?

Kevin Lavery

For their pathology service and I thought we want that in Lancashire and South Cumbria.

Matthew Taylor

Yeah, it’s fascinating. I was chatting to a leader a few days ago about whether she was going to come because obviously with the junior doctors strike, and there’s going to be a demo here today I think, it was difficult for people to come, but she said that for her what ConfedExpo is about is that all year she sees interesting bits of practice and then she uses the app to arrange to meet people, to talk to them about that practice and see whether she can bring it back into her system. So yeah, that's a great example.

And then, last but not least, Amanda Sullivan, ICB CEO, Nottingham and Nottinghamshire, and Amanda, I should just say before I ask you how the conference has been, how sorry we are about what's happened in Nottingham. It's a really terrible and tragic thing and must have had great implications for the staff. But notwithstanding that and I know you're going back today because it's a vigil of some kind, but I wondered how conference has been for you so far.

Amanda Sullivan

Yes, thank you. Yes, it's been a tragic set of events in Nottingham and devastating for the families and the communities as well. But I think one thing that gives me heart is that coming to this conference, I was part of a panel on the cost of living, the rising cost of living and the impacts of that. I think probably even a year ago that wouldn't have been a main agenda item.

And that just shows, I think, how we are thinking more broadly about health, the impacts of health and how systems can come together to address causes of inequalities in health. I think that that gave me heart and there was some very, very rich conversation in in that panel thinking about how partners had really come together with communities to make a real impact on that.

So, I take great heart from the broader view around health and health inequalities at this conference. I think also in Amanda's speech, for example, that reminded us of despite the very considerable pressures, there are also some great achievements.

Matthew Taylor

Yeah, and cost of living has been a big thing for us as well. There's a lot around it on our website, and the NHS Employers website, because it's a double effect isn’t it, Amanda? It’s effect on the people we serve, but of course it's an effect on our staff as well.

Amanda Sullivan

Absolutely, yeah.

Matthew Taylor

So, let's turn to integrated care systems. A year on, as Kevin reminds us, that's why you weren't here last year. Amanda I'll start with you. What do you think we've learned over the last year about ICSs? As you know, still very early days, but what do you feel has gone well? What is challenging? What's at the front of your mind now, one year on?

Amanda Sullivan

So, I think we have to think of the work of the ISIS is in three different categories, essentially. One is about managing today, another is making the space to make things better for tomorrow - in health terms, population and wellbeing terms. And then the other is being careful about how the system is developing. And I'm really pleased that I think the way that we work is vastly different from what it was a year ago and very much different again from the previous year.

So, I think the idea of mutual accountability, co-production and bringing different perspectives together to solve really wicked problems like urgent and emergency care pressures, elective backlogs, primary care resilience, is definitely much more the norm now rather than something that we thought would be a different way of working.

And we can see that now in some of the achievements that our place-based partnerships are making around how they're transforming the community services by really marshalling all the assets in local communities and having a very different model, much less of a medical model in local community services. So, I think there are definitely different ways of working. I would say we're definitely not the finished article yet. There's a lot to do, but I think pockets where it's really encouraging and that momentum I think will gather as more evidence of impact grows over time.

Matthew Taylor

And Patrick, you’re interim chair of a system where there's been a lot of change mainly around the kind of big shifts in Birmingham Hospital. Has it been possible to make progress within the ICS, despite the fact that there's been these kinds of big changes taking place?

Patrick Vernon

Absolutely. If you look at Birmingham Solihull, as a system, you know, we've got quite a few major health providers. We've got a large primary care infrastructure. We've got the biggest local authority in Europe that we're dealing with. And we've got the worst health inequality data. If you look at the work that was done by the Health Foundation, Birmingham and Solihull and our neighbouring ICB, ICS area, the Black Country, we were the top two in terms of deprivation. So, despite all of that and it's not all doom and gloom, at times it feels like doom and gloom, it really does, actually, because we've got big challenges. Particularly around some of our providers.

But despite that, I think just build on what Amanda made we’re different from CCGs, we’re different from the old health authority. We try to set up a new dialog, a new relationship with primary care, a new relationship with local governments, new relationship with communities and our trust providers. That's been a challenge.

But we can see some of the evidence of that because if we just look at the basic metrics of our performance, we weren’t a fantastic system about a year ago or even six months ago. But I think the results of hard work, collaboration, building mutual trust. Despite the strikes, challenges around service delivery, access and people's expectations and staff expectations as well as patients’ expectations, we start to see some of the evidence of change. The challenge for us is how do we build on that, without going back to the old ways of doing business.

Matthew Taylor

Yeah, that's really interesting. And Kevin, both Patrick and Amanda have talked about relationships and that seems to me to be a kind of critical factor when I talk to leaders. If relationships are strong and they're developing and they're growing and collaboration feels real, things do start to happen.

So how have relationships developed within your system and is collaboration starting to feel real?

Kevin Lavery

Yeah, I was lucky. We're a big system, but actually we've got a small number of health trusts in our area so you can get everyone in one room around one table. So, I think that makes it easier. I do though, think we were born at a difficult time. We face a huge range of challenges and there needs to be some pain and tension as part of this. Otherwise, you're not really facing up to the issues.

So, there is pain and tension in our areas. We made a very early decision, for example, unlike many areas we didn't have co-terminosity with local government, we decided to make that change at our first meeting. Primary Care weren't happy about it. Many people in primary care. But actually, you've got to have those arguments and discussions and debates about some of the tough issues. I think we're making good progress in that area now.

It was the right thing to do because in the long term if we're going to integrate care and health, we've got to make it easier for local government to participate. But not everyone was happy with it, and I think that's part of the trick. You know, we've got five trusts in our area. We want to see a single collaborative bank, shared services across the area with one platform, a rationalised elective care system. Not everyone will be happy about all of those changes, but we've got to be grown up enough to go for it. And I think we are getting into that space, but it is going to be bumpy along the way, for sure.

Matthew Taylor

That's really interesting and let's look at a couple of dimensions of that, Kevin. Somfirst of all, in terms of place. Patrick, you're an interesting person to start the conversation because of course you also have a focus on place, in terms of your work in Walsall. So, you know, I was in your neck of the woods a couple of weeks ago. And really interesting because I think Black Country's got four places?

So, my sense was Walsall has been working as a really tight-knit place for quite a long time. Wolverhampton is moving along that road, kind of quite driven by the hospital, but I can see that same collaboration, Sandwell as well. In Dudley, things are more challenging, so I'm interested in your sense of how does the system add value when so much is happening at kind of place level? But also, when the places within the system are at different levels of evolution themselves?

Patrick Vernon

Yeah, it's interesting you mentioned that, I was talking to one my colleagues on the conference, Michelle, who's leading our transformation work around the Walsall Together Partnership. I said to her, because she attended a session I did on the NHS anchor institution, and this is the kind of stuff that we're doing in Walsall and we’re also starting to do in Birmingham, Solihull as well.

And what I said to her was that what we need is a Walsall Deal. Everyone talks about the Wigan Deal, we need the Walsall Deal. I mean everywhere needs a deal and that deal involves working with lots of representatives, working with the community, working with senior leaders in NHS, local government, third sector on some key priorities that everyone's going to work towards.

But to do that you need to have that maturity of trust, confidence, partnership working. So, in Walsall that's happened over the last couple of years and I've been very lucky to inherit this. I'm very lucky to work with some fantastic leaders in local government, in the NHS and the third sector. And I think when you came up to see us, you saw it for yourself in terms of our work. It's that maturity and this is going to be one of the challenges I think for ICSs and ICBs because there will be some ICB that's already got that perfect form in terms of X number of partners that can work together and have a meeting in one room.

In an area like Birmingham and Solihull, Birmingham is such a massive area, even though we've got a place committee, it's still very strategically high up. So we have to work down at a neighbourhood level and at a PCN level to really make that difference, and that requires extra legwork, more confidence building, more communication up and down and sideways so people feel that they are connected.

So it does require extra work, but I think small is beautiful, and I think in terms of the work that we're doing in Walsall that’s influencing the places in the Black Country and I think it's quite a good model and it would be fantastic for the NHS Confederation conference next year, to have a theme on area-based conversations.

We have big conversations around the big aspects of our NHS care and delivery, but actually, as Sun Ra, a jazz musician friend of mine, would say space is a place, area is a place, so let's work towards that.

Matthew Taylor

Now it's interesting. Amanda, tell us a bit about the kind of the geography in terms of your ICS and how you see the system adding values to what happens at place and neighbourhood? Because, of course, the fascinating thing about ICSs, one of the reasons I think sometimes people in Whitehall can't really get their heads around them is they are so incredibly varied.

I was up in the north eastern north Cumbria the other day, this is 4 million people, the 11 acutes or whatever, that is huge. Absolutely huge. Then talking to the leader of Somerset, I think Somerset is a single system, single place and now just one trust. So, the question about how you add value as a system in those two places, completely different kind of question. So how do you think about that Amanda In Nottingham and Nottinghamshire?

Amanda Sullivan

So we've got four places and they are really different. Like Kevin, we had a boundary change as part of the establishment and that was very beneficial, I think in terms of aligning with our local council and that area is quite rural, very near to South Yorkshire and got some old manufacturing towns in it.

So some areas of deprivation, some quite affluent. We've got the inner city, the city of Nottingham and then the boroughs around that in the south and then mid Nottinghamshire is the old coalfields and again a lot of deprivation in that area as well. So, they are all developing different characteristics and personalities based on their local dynamics and their relationships with communities, which as a system we have encouraged and tried to encourage the place-based partnerships to be very broad partnerships.

And that means reimagining what you might think are places from an NHS perspective, much more leaning towards how councils would develop places. So that's been a bit of a journey and continues to be, but there's definitely a different mindset around that. In terms of what we can add differently as a system, I think we can put those frameworks around what we want the places to focus on and the population-sensitive local relationship-dependent services are very, very much in the domain of the places now, the delivery vehicles for those.

Also, I think we have agreed it's the whole system like everywhere, an integrated care strategy which sets out the big health priorities for our population. And again, they provide a framework for how the places are developing their delivery plans. They'll have different ways of implementing different focuses on different outcomes depending on their particular population needs.

But there is that framework there, which is agreed across the NHS and local government. But also, I think we can provide some of the support for development infrastructure. We've got convening power, so we do help with that. I used the example of cost of living at the beginning. What we did there was we used our population health management analytical capability at system level.

We overlaid a lot of data around poverty measures with GP data to show where there might be poverty and ill health, where we needed to really target interventions. The places then had that data and used it with the sort of voluntary sector colleagues to target the interventions to their communities. So, we provided them the information to then use that in a way that was locally sensitive.

Matthew Taylor

Yes, really interesting example.

So, Kevin, tell us about the kind of geography of your system. And again, this question of how you see yourself adding value to what happens at place or even a neighbourhood level?

Kevin Lavery

So, we're a population of just under 2 million. We've got four principal local authorities. We've got medium sized towns of Blackpool and Blackburn with Darwen. We’ve then got Lancashire with two tiers and we have a place-based partnership there with three subdivisions, for north, central and west and for Pennines. And then we have South Cumbria, which is a little bit tricky because we've got two thirds of the new unitary council, Westmoreland and Furness; we've got a sliver of Cumberland and a little bit of North Yorkshire as well.

It's a bit complicated. They're all different places really. So you've got very compact places like Blackburn and Blackpool with very challenging health outcomes and then you've got diversity within Lancashire and then you've got all the - actually South Lakes is England's most rural, sparsely populated area. So, lots of challenges and opportunities there. I think in terms of where does the system come in, we've got some huge issues around money and our challenges around money are really around how we do things around here and how we're configured as a system and that really can only be done at that regional level, if you like.

But on the on the flip side, the solutions lie in reorientating our system to the community side of things; prevention, you know, the sort of Hewitt agenda, if you like, and that can only be done at place. So that's why we were determined to change our place-based boundaries, to align them with local government to allow the integration to happen.

So, we're probably behind some of the other areas, but we're catching up fast and I'm quite excited. But a lot of that happens at place an even more happens at neighbourhood level really. So we're rolling out neighbourhood teams. There's been a strong tradition in parts of our area. In Morecambe Bay, for example, we're rolling that over the next two years across the whole area.

We want to see a virtual hospital, not just virtual wards, and we're perfectly placed for that. We've got some big rural areas which really should be exemplars for that sort of agenda. We want to see investment in areas like intermediate care and really target those individuals who are at high risk of admission to hospital or in hospital with relatively moderate health and care needs who really should be at home.

But these things take time, those solutions can really only be done at place level.

Matthew Taylor

Staying with you, Kevin, what's interesting, listening to all of you is the emphasis on community, the locality, the geography, the variations within your places. And that reminds me to things which are kind of challenging to the way the NHS tends to think about accountability.

So on the one hand, still the most important national body in our minds by a long way is NHS England. And Amanda was here yesterday, and Amanda is here as our kind of leader. But in a sense, she leads the NHS and now increasingly your relationships are with people who are beyond the NHS. So here you are accountable within the kind of NHS stovepipe, but then having to build relationships for people beyond that.

And of course, the second dimension is the secretary of state will be here today, no doubt reiterating the importance of national priorities, particularly around waiting lists. But yet you need to have the capacity to have local priorities which respond to very different kinds of local issues. Maybe the elective backlog would not necessarily be your number one priority in your different areas.

So we've heard the government's response to the review, which is, as our chair Victor said, doesn't give us everything we want, but broadly suggests the direction, a devolutionary direction, the new NHS operating model also points in that direction. We hear there's going to be a new NHS mandate, which we also hear will have this kind of devolutionary message.

So I guess Kevin, two questions really; one, how are you understanding that conundrum of where your accountability lies between this kind of traditional NHS stovepipe and that lateral accountability, and what are your hopes? Because at the moment it feels as though there's a bit of a disjunction between the national commitment to devolve to systems and the actual reality when it comes to things like the planning round where it feels like a fairly traditional kind of central relationship.

Kevin Lavery

Yeah, it was a bit of a shock coming into health and having two hundred priorities, that's for sure, and they’re increasing as we go forward, if anything. And obviously with an election approaching, there are a number of areas like winter pressures and all of that that you can see why you need to be on the case. But at the same time, I guess in my area, long term, we need to rebalance the system towards the community side of things. It's very much in line with the Hewitt thing and it's a bit of a balancing act you need to go through.

But I'm always the optimist and having worked in local government where we went through austerity several times - we had to make some very tough decisions - we have some of those tough decisions in health now, but I see lots of opportunity in terms of, if we reconfigured our system in a better way, we can unlock a lot of value to do some of that investment in the community services going forward. If we could create better relationships on the challenging issues with local government, we've got the Better Care Fund, we've got ring-fenced monies for social care which are due to grow over the next few years.

So there's a real opportunity there. So yeah, big challenges, but there are lots of opportunities and I think that's the exciting thing for the integrated care boards. The trick here is to pick a small number of things, really get them over the line, build confidence to do the harder, tougher things all the time. And I think that's the craft of leadership, isn't it fundamentally?

Matthew Taylor

Patrick, how does this issue of accountability, again, recognising that you're both interim chair of one system and very active in another system, how does this issue of accountability feel to you? These two contrasting ideas, the narrow hierarchical NHS model and the wider lateral kind of system in place model?

Patrick Vernon

It’s an interesting one we need to think through. What Patricia Hewitt did in the review was a good foundation that we need to build on, and I think in the months to come we need to work out what does devolution look like? Because when people think about devolution, you think about in the context of politics, local government, as opposed to devolution, which is simply to say what we're given to give you some more responsibilities, but we're still holding the ring.

So the question is how much of that ring do we have? And it is a difficult one because on one level we talk about system leadership, we talk about collaboration and partnership working, but yet there's a degree of performance management that we have to do as well as an ICB, and how we work in partnership with both our local authority colleagues and Birmingham and Solihull.

And also how we’re accountable. So in Solihull, which is completely different to Birmingham in terms of geographical size, politics, etc, it's only got one deprived area, in terms of wards, and most of it's quite affluent, but they still have key issues around safeguarding, that we have a responsibility with the police and crime commissioner and with the Met Police.

So there are certain things that we have this joint responsibility for, where there’s expectation from the public and government that we need to have a kind of clear grip on some of the issues around interface between health and social care. So there's a clear accountability on that level. But I think the question is, do we want more power?

Yeah, we want more power because I think when we created the ICB, just before we launched, we launched an inception framework, which is a vision. We use it as a template to develop our health inequality strategy, our ten-year strategy for the ICS. And now we're developing a five-year joint forward strategy as well. And that inception framework tells our stall of making a demarcation with the past, and what we want to achieve for the future. And part of that demarcation is that we want to have more decision-making at a localised level. I mean, eventually I think I would see the ICB and ICS structures would be much smaller in future and therefore really devolve down to neighbourhood level, because that's where delivery is taking place. That’s where people's needs are, that's where we can actually engage with patients and the community as opposed to just looking down all the time.

So that's part of our job around this transitional situation. We want to be devolving, but we want to have that devolved power from us and down to kind of community level. And that's the next bit of the work. That's the conversation that we need to have with NHS England. And if we are going to give powers of devolvement, then let us devolve further down without them telling us how to do it.

Matthew Taylor

Well, that chimes Amanda with, I said in my speech yesterday, there is a kind of cultural challenge here that when we talk about accountability in the health service, we tend to think about accountability upwards to the kind of tier that controls us. And how do we take that idea from Cathy MacLean who talks about inverting the pyramid, where accountability is about how you empower the level below in the way that Patrick's describing it. So how do you think about that kind of accountability conundrum yourself?

Amanda Sullivan

Yeah, so I think one of our roles is to help navigate that and explain that to local partners. I think there are some things the NHS is a national health service and therefore there will be things we are accountable up-the-line for. I think our local government partners understand that. They might not necessarily be alongside us for all of it, but that's okay.

We've tried to be more deliberate about the agenda, so we're not wasting the time of our partners in things which are sort of quite technical NHS type things, and we've got more discerning over the time so that it feels more of a real partnership when we are together. So, I think that's absolutely right. And we do see ourselves as kind of the small part of an inverted pyramid with a convener, enabler sort of role, but that does come with a bit of an edge to it because at the end of the day, there's no point us being there if we're just bringing people together for a nice conversation and it has to have impact.

And we do have duties to get the best possible health services we can for the people that we serve. So, it does have an edge to it. But I think if you've got the relationships there, like Kevin says, you can have the more difficult conversations without it feeling personal or undermining. So I always try, I’ll say to the teams, be tough on the issues and uncompromising and ambitious for the outcomes, but careful about relationships because things can get very difficult very quickly when there's a lot of challenge and blame.

So, I have a distinction in my mind about the things that we just need to get sorted from an NHS perspective and we're held to account on. And then the things that we work through together and I think the integrated care strategy has been a good process in working out what our joint priorities are. I think also we are increasingly held to account jointly and that helps because it means we look at everything; we look at the data together, we look at the whole pathway, some of the inspection regimes now around children and young people with SEND.

Some of the discharge taskforce work, that has been very much about what is the effectiveness of the partnership, not just are we playing nicely, but what impact is it having? And I actually welcome the bar being raised on some of that because I think it helps focus the partnership.

In relation to the places, I think as I said, they are delivery vehicles. I think we have to ensure that what they are doing contributes to the whole population outcomes or objectives and helps with delivery of some of the imperatives alongside that space to think about their communities differently.

Matthew Taylor

Yeah. I'm going to ask you all a final question in a moment. But yeah, I'm a policy wonk by background, so I find this moment absolutely fascinating in the sense that what's happening is we're moving in the health service towards a more permissive, more devolved kind of culture.

Local government is actually going in the other way, slightly because councils are going bankrupt and having enormous debts and stuff like that. And the creation of OFLOG as a kind of regulator of local government. So in a sense, if you go back two years, our worlds were completely different; very centralised NHS, a kind of attitude to local government, for central government, which is you've got no money but you can do what you like.

And now I think they're kind of converging. The NHS is trying to be more devolved. Local governments probably going to have to have a little bit tighter oversight. So that is an opportunity I think to look at how we get these accountability systems working together. And then you've got the fact that ICPs - integrated care partnerships - and places kind of exist in an accountability and support vacuum.

I mean, they aren't really accountable to anybody in the sense that they can't be accountable to NHS England because they're much wider than that. And I talk to colleagues in DLUC all the time and you know, I'm getting them interested in this. I was talking to the head of the levelling-up unit a few days ago. The head of the levelling-up unit is going to come to our Place Forum.

Trying to kind of get central government to recognise that DLUC, DHSE - other bits of government that have got an interest in health, I mean, DWP has got a big program on getting people back to work - that Whitehall has got to kind of join up because these system bodies, place bodies are looking much wider.

But I don't think central government quite knows how to engage with us. And I think from our perspective in the Confed, it's a really important role for us now to do that national convening which works what you're doing locally.

Now last question, if I was to gather you all this time next year, what is the one thing that you would hope you will have achieved by then? Tough question. I know. Who am I going to pick first? Amanda, I'm going to go to you. In 12 months’ time, what's the one thing you hope you'll be able to say? Well, we've done that now.

Amanda Sullivan

I would like to think that we have got really embedded integrated community teams in all of our neighbourhoods and that we are starting to see a shifting of the dials on some of our inequalities. Being a bit naughty, I think also we have got immediate imperatives that we need to deliver to get more resilience in the system. So that's two things really.

Matthew Taylor

No, that's fine. Have as many as you like. Patrick?

Patrick Vernon

Kind of building on what Amanda said, I'm working on our primary care committee collaborative, so which is really about wholesale integration between primary care, secondary care and community. I hope that this time next year, not only have we startsx to implement that, but actually people can see the benefits of that true integration agenda. That's the first thing.

And the second thing is we launched a Future Power Fund about nine months ago. We're giving money to Birmingham, the whole local authority. It's going back to the point you've just raised Matthew, about local government having limited resources. So, we decided as a system that would give them money on our behalf so that we could give it to third sector organisations, other partners around this health inequality prevention integration agenda. I hope by that time we have some clear, tangible activities and projects where we can actually help us think through the way forward from achievements and ten-year strategies at ICP.

Matthew Taylor

Fascinating. Kevin, that both Patrick and Amanda are focusing on this kind of integration at neighbourhood community level as a critical objective, would it be the same for you?

Kevin Lavery

Yeah, on similar lines. I mean, I'm a Newcastle United fan, so I like all things black and white and I think in 12 months’ time I'd want to see hard evidence that the focus on investing in community services - so things like our virtual world programme, our intermediate care facilities, proactive approaches through primary care too.

But really focusing on those at the most risk of being admitted to hospital or who are in hospital who shouldn't really be there and seeing hard evidence, tangible evidence that those things are starting to work. So, less pressure on the hospital system going forward and a lot of people avoiding admission. So those hard tests, I think, are going to be important.

Patrick Vernon

I wanted to add about Walsall Together, in terms of Walsall Together that we have a Walsall Deal. I don’t know what it will look like, but it’d be great to have a Walsall Deal.

Matthew Taylor

Great. Well, Patrick, Kevin, Amanda we're going to have to invite you back next year and see what progress you've made. But this has been a fascinating conversation.

For those of you who haven't been to join us at ConfedExpo do go to the Confed website. There's loads of content there in terms of speeches and other activities that have taken place over the last couple of days. But thank you all for joining me.