Is shared NHS leadership the new norm?

MATTHEW: Hello, and welcome to Health on the Line with me, Matthew Taylor. In a moment, I'll be speaking to my guests, Paul Roberts, a former NHS chief executive, and Stacey Hunter, group chief executive of University Hospital Tees. We'll be discussing a new NHS Confederation report on shared leadership models, which was released last week.

But first, I'm delighted to be joined by Chris Smyth, Whitehall editor of The Times. After an award-winning stint as health editor, leading coverage of the government's COVID policy during the pandemic, Chris now covers all aspects of government, and in particular, the fine line between politics and policy. I've written loads of blogs about the kind of different logics of politics and policy, and how in recent years politics has triumphed over policy, but that's a different podcast.

In recent months, Chris has written extensively on the country's tricky problem of soaring economic inactivity. That's people of working age who are not in work or in training. And he's also explored the government's proposals to get people back to work, to keep people in work. 

So Chris, welcome to Health on the Line.

CHRIS: Thank you, Matthew. And yes, politics and policy is always a fascinating intersection. 

MATTHEW: So Chris, we, we know the country has a sickness problem with demand for health and care services higher than ever before. And a significant part of that is 2. 8 million people economically inactive in large part due to long term illness.

And we also know that Britain's an outlier on this. So the most kind of powerful statistic there is that other countries have returned to the level of economic activity before COVID, whereas we, I think, are nearly a million more people of working age, economically inactive than before COVID. So I guess, Chris, the first question is, what's your take on why this is happening?

CHRIS: Yes, I, I think it is a really alarming trend and, uh, and it isn't fully understood. And one of the things I slightly find frustrating in government is that hasn't really been a proper sense of urgency to understand exactly what is going on, given the costs to the individuals, of course, uh, but also to the public finances and to the wider economy.

But I think from what we can tell, that sort of broadly, three things going on here. There is obviously sort of underlying deterioration in the nation's health. We are older, we are sicker, as I'm sure you've talked about many times on this podcast. Over recent years preventative services have not been what they are.

Our lifestyles are not great. And that I think particularly COVID gave a big shock to a lot of that and tipped a lot of people over the edge. So that big structural thing underlying it. I think there's also something very specific about mental health, which is the fastest growing reason for people to be off work and claiming benefits for long term sickness, both in the sense of, you know, there are lots of things making us, you know, more miserable as a society that's contributing to depression of anxiety, whether that's social media, Or other things, uh, cost of living and so forth.

And there's obviously a cultural thing there about people's willingness to come forward for help and indeed to conceive of their problems in medical terms. And then I think finally, there is a structural thing in the way we've set up both our health services and our benefit services, which just pushes people into this funnel of being signed off sick when, you know, that is not necessarily best for them or for the economy.

There is, you know, years of job seekers allowances cuts and the crackdowns on that area has meant that there is a big financial incentive to see yourself as ill and understandably people respond to that. And the problem with the system we have is once you've done that, it's very hard for people to look for work because they're worried very understandably about losing their benefits.

So there is an awful lot of causes to this and that's why it is going to be very difficult, I think, to put it right. 

MATTHEW: Yeah, so one of the things that's interesting to me, Chris, about this is that we have been here before in the sense that when I was working with the government in the, uh, late 90s, early noughties, the big issue then was older men.

And that was the kind of long shadow of the 1980s recession, the shakeout of manufacturing. And there was a lot of pessimism then about ever being able to do anything about the kind of rate of employment of kind of men over 45, 50. But actually that then changed over the subsequent years, probably as some kind of combination of changing economic circumstances, those people just in a sense, moving through into retirement, dying off.

And so it was a kind of cohort effect and also new, more proactive labor market policies. So, I mean, before we get into some other elements of this, it is instructive, I think, isn't it? That we have had this problem before, though, in a slightly different form, and we have been able to make progress on it before. 

CHRIS: Yes, and it is worth saying that one of the reasons why we're focusing on this is because of the big success in, in bearing down on unemployment, which was obviously a really key issue back in the eighties and nineties.

And indeed some of the perhaps ways in which successive governments have responded to that has perhaps pushed people more towards these kind of sickness benefits and sort of contributed to the problem. But yes, I mean, you know, this is not something that is by definition intractable. There probably are things we can do.

We're just perhaps in the early stages of working out exactly what is the best way to fix it. And you mentioned older men there, perhaps the most worrying thing about this new trend that we're seeing is that it is particularly striking in younger people. I think your report you did, you know, with the Boston Consulting Group showed there are tens of thousands of young people now going straight from studying to being signed off for long term sickness. And that is a very worrying trend for them, you know, because that affects the rest of their lives. And of course, you know, it has knock on effects for the services for decades to come. 

MATTHEW: Yes. And one of the things I remember from the research and the policy in the past was the scarring effect of unemployment at any point in your life, actually.

And so, the younger you become economically inactive, that will have a lifetime effect. You might go back to work, but the evidence suggests that as it were, each time you're economically inactive, it makes you more vulnerable to that in the future. So, so Chris, let's turn to the future. You recently reported on an OBR analysis that found that by 2070, there could be a million fewer people in work because of uh, ill health and that spending on sickness benefits would rise from 65 billion to more than a hundred billion.

So I guess two sides to this question. What is, you know, as you kind of said earlier, do you think with what the government saying they are recognising the scale of this challenge and the other is the opportunity that exists there? Because clearly, when I speak to people in the Department of Health and they're talking a bit about this and kind of the growth mission in government.

There is here an opportunity to count health and care investment as investment, not just spending, if you can demonstrate that it will get people back into work, not claiming benefits and instead paying taxes.

CHRIS: Yeah, absolutely. There is a huge opportunity here precisely because the challenge is so big.

The OBR has really been sounding the alarm on this after the budget. They said that spending on sickness benefits of all kinds would reach a hundred billion by the end of the parliament. And to put that into context, it's 65 billion now before COVID it was 36 billion. So that's, you know, almost a 70 billion increase.

And if you think what 70 billion could do for other public services, if we were able to prevent that rise, that is, you know, an enormous prize. Uh, and the OBR has said that, you know, the health of the nation is the single biggest factor that is going to determine the sustainability of the public finances in the decades ahead, which is why I started by saying, I am surprised that this has not become much more of a consuming focus within the treasury and other parts of government.

They are asking about it. They are thinking about it. There's work going on to look at it, but the urgency, I think, possibly needs to be stepped up, because, you know, which trajectory we take, the positive or the negative, is hugely consequential for the whole of government and society. 

MATTHEW: Yes, and it also links, Chris, doesn't it, to the argument that has been made eloquently by Chief Medical Officer Chris Whitty, which is that we sometimes talk about population aging as fate, but in fact, population aging would not be such a problem for our labour market and for our fiscal situation if only we could help people stay healthier for longer. My final question, Chris, we produced a report, a Boston consulting group, uh, "Improving our nation's health: a whole of government approach to tackling the causes of long term sickness and economic activity". And that really focused on this issue of mission driven government. If we're going to solve a problem like this, we really need to join up, you know, because to keep people in work when they're sick or to get people back to work, it's a combination of improving the quality of work, the role of proactive labor market policies through DWP, the way we provide health and care, probably housing is an element of all of this, transport is an element of all of this, particularly in rural areas.

How confident are you, Chris, as you observe Whitehall and government that this kind of commitment to mission driven government really is going to help, on the one hand, people spot the Whitehall, and secondly, enable Local institutions, ICSs, local authorities, give them the space to really join up at a local level?

CHRIS: So I think there are two ways of answering that. I mean, the sort of pessimistic way is to say that Whitehall is terrible at joining up across different departments. That's why, uh, you know, this idea of missions came in in the first place, but is already sort of fading very noticeably. You know, the prime minister was meant to be chairing these mission boards.

He isn't, he won't. And therefore, you know, Whitehall has basically given up on them already, but there is a more optimistic argument, which is, you know, the government has come and recognising explicitly that, that it does need to think long term. It does need to think cross government. It does need to move things upstream.

And it knows that it isn't going to be judged really over the next year. It is going to be judged in five, possibly even, you know, 10 years. So that there is a unique, perhaps political opportunity now to actually make some of this happen in a way that just hasn't been under previous administrations, which was sort of trapped in short term spirals.

And there are some interesting ideas out there to look at. I've been writing, uh, as we speak about a proposal, perhaps to make nice, take into account the cost of, uh, to the welfare system of sickness and therefore perhaps given an incentive to approve more preventative treatment. You know, all these kinds of things are out there and we need to be up for discussion because we do need, I think, a little shift in how we approach sickness and prevention, something that obviously, you know, pretty much I imagine every guest you have on this podcast talks about, but we really have struggled to make happen in any systemic way. 

MATTHEW: Chris, thanks so much for joining us on Health on the Line. 

CHRIS: Thank you. 

MATTHEW: Before we get into the next part of Health on the Line, I've got a bit of a favor to ask.

If you're a regular listener, in which case, thank you - or if you're tuning in for the first time, in which case, well done - I'm really keen to hear what you think about this podcast. In a way, I'm turning the microphone on to you, so you can have your say. If you could spare just five minutes, it really is just five minutes to complete a short survey, you can help me, you can help us at the Confed make Health on the Line better, more relevant, more useful to you.

You'll find the link in the show notes. I really look forward to hearing from you.

Anyone that follows developments in the NHS will be aware that over the last few years, there's been a move in many areas to NHS trusts working together much more closely with those in their local patch. Specifically, we're seeing some trusts forming groups, sharing a chair, chief executive, or even the whole board of executive directors, but while still remaining as distinct organisations.

So in light of this trend, we've commissioned research here at the Confed, and that's led to a new report which we're publishing. The research was conducted by Paul Roberts, who's recently retired from the NHS after 28 years in leadership roles. Paul conducted interviews with very senior leaders on the background benefits and potential challenges around group models, and he's here with us today.

I'm also joined by Stacey Hunter, Group Chief Executive of North Tees and Hartlepool and South Tees Hospitals NHS Foundation Trust. And Stacey, who I visited recently, will be able to share more with us about what group models mean in practice from her perspective as the leader of two groups trusts. Paul and Stacey, welcome to Health on the Line.

STACEY: Thank you lovely to be here 

PAUL: Great to be here. 

MATTHEW: So Paul, I read the report before this conversation and it's it's a really good read - really clear, really balanced. But let's start with the basics. What are we talking about when it comes to shared leadership models, what what are those models and why does this matter?

PAUL: Okay, so if you go back 10 years, it was an option that didn't exist really in the nhs. So Either you had NHS trusts or foundation trusts acting independently, usually in one sector, so either acute community or mental health, running their, their bit of the local NHS. And if they wanted to get together with a, another local organisation, and it was usually two hospitals, they had to do that through a formal merger, and that of course did happen.

But about 10 years ago, Sir David Dalton wrote a report for NHS England which suggested an alternative, and that was, uh, organisations coming together short of a former statutory merger. Now he wrote that in the context of viability problems for some organisations and the, the, the attempt to get organisations to become foundation trusts, a context which of course doesn't exist anymore.

But over those 10 years, there's been an increasing number of NHS provider organisations coming together short of a merger. And indeed, what we know now is that over a third of NHS trusts are part of one of these shared leadership roles in which, as you said earlier, Matthew, they, at the minimum, they will share a chair.

So that would join chair for their boards, often share a chief executive. But in most cases, they go further than that. They have boards in common, they share governance arrangements, they develop common strategies. And in some cases, it's a stepping stone to merger further down the road. And I suppose, what I would say about why it matters is of course, to patients, members of staff and even to politicians, the form of NHS organisations is confusing and doesn't matter.

However, how well NHS organisations and provider organisations specifically work does matter. Quality of healthcare, how productive they are, what their culture is. That matters a lot to the people affected. And I think most of us who work in the NHS provider sector would say the way NHS trusts and provider services are organised has an impact on how successful those organisations are.

And what I found was, was that a lot of these changes to form groups, short of the statutory model, was going under the radar. It was being picked up in the news pages of the health service journal. But as a phenomenon in its own right, it really wasn't going particularly reported or studied or examined.

So we thought it was really important to do that. 

MATTHEW: Great. And, uh, and, you know, at the risk of a kind of spoiler in terms of your conclusions, it seems to me that what you're advocating really is that on the, whilst on the one hand, the development of these models needs to reflect local circumstance, there is absolutely not a one size fits all. We should be reasonably kind of agnostic about this and allow it to organically develop. On the other hand, that doesn't mean that we shouldn't be clear about the benefits, the problems, that there may be a certain kind of palette of different kinds of models that organisations might be supported to take.

That, that's the kind of happy middle we're trying to achieve here, allow people to do what works for them, but to do with a bit more clarity and a bit more support. Anyway, that's what I think your conclusion is, but although it's underpinned by a lot of really good recommendations, but what are the real and potential advantages of this way of working?

PAUL: Well, as you hinted there, Matthew, one of the things they do is they offer flexibility. So in a sense, it's, it offers you a toolbox rather than just one particular tool. So it gives you a variety of different models that you can change within something that you would broadly bracket as shared leadership.

So, um, for, for example, one of the main reasons that, that NHS organisations come together in this particular way is because of fears about sustainability and viability. On their own, they're too small, but if they develop a joint strategy for their services, serving a local area. If they share some of the key director roles and some of the decision making, doing that together makes them more sustainable, able to offer a comprehensive range by working together and doing it together, as opposed to trying to do it on their own.

Equally, another advantage that, that some of the, the, the, the groups, the shared leadership models come up with is, is a slightly different one, which is sharing the, the management of pathways of care. So traditionally acute hospitals used to merge with acute hospitals. Now, quite often, you're getting arrangements where an acute hospital and a set of community services or even more rarely, but sometimes mental health services come together and a local organisation very firmly bedded in a place with links to local authorities is able to offer oversight and governance of connected pathways of care.

So they become more sustainable, they become more coherent, there are fewer boundaries in play. And that can be a, a huge advantage. And if, and it's the case for some of them, and I'm sure Stacey will talk about this is, if the eventual destination is that they merge and become one statutory organisation, what shared models short of a merger offer is the chance to work on some of the things that often block organisations coming together in mergers, which is distrust between organisations that have been rivals in the past, cultural differences in terms of the way they're led, so you can start bringing people together, getting them working together, getting them working on pathways of care, on investment in capital and that that sort of breeds a really good environment for perhaps further coming together later down the line including mergers. So, so they can act as a good seedbed for growing organisations which come together even further in the future. So those are just three of the the advantages which I think stand out.

MATTHEW: So Stacey you're, you're not just uh bringing two groups together as it were but you're in a part of the country where every acute trust has merged with its community providers. So we're talking about merger and group. It's a, it's a kind of interesting organisational form. You've obviously not been there that long.

And in a sense, you don't have the past to compare it with. But does Paul's account of the, of the, of the potential benefits resonate with you? 

STACEY: Yeah, so it really does, Matthew, and as you say, I only joined in February, so I'm really cognizant that, you know, I have, I guess, that limited experience thus far, but I suppose the history, some of which you've described in the Northeast, was the two acute trusts in particular had kind of always rivaled each other, and, you know, we're in a different context, aren't we, these days, around collaboration, but We've been in a 10, 20 year history of competition for resource.

And when those hospitals are only six, seven miles apart, when actually for Teesside, for people who don't know the geography, sits as part of the broader Northeast North Cumbria, where you've got Newcastle up in the North, where there's an understandable and obvious dominance, if you like, of trainees, you know, of the type that we all need.

So in a way, it detracted more broadly from the Tees Valley being able to lobby on behalf of the Tees Valley, because actually there was quite a lot of lobbying in between. And, you know, if I'm really honest, I think that probably made it easy in some respects for you know, commissioners, politicians and others just to always kind of badge the inability to deal with some of the things on behalf of our communities as because the organisations kind of, you know, were busy in fighting.

So we kind of came together in the way you described of the, of the spectrum of things that Paul just described. We have gone for what I guess is described as a pretty hardwired group. So, we're very fortunate we've got community health services in both organisations, as well as secondary and tertiary care.

But everything but our RemCom decisions, some of our audit and some of our charities is all operated under a single joint board by virtue of a joint committee. So in essence, from a strategic point of view, and a resource allocation point of view, and a priorities point of view, we have a single, if you like, set of people who are able to work with colleagues to determine that.

We're literally in the midst of, I guess, a big plank for us for obvious reasons is a, a new and different kind of clinical strategy. So, you know, what is it we want to do? You know, now, if - and the conversation we have all the time, I have with colleagues is if, if you just step back from everything and looked at the resources that we've got available to us, whether that's our people and our talent, our buildings, our money, and thought about what would we do to really respond to the people in the Tees Valley, you know, an area of significant deprivation and poverty with huge challenges around that kind of health wellbeing and some of the inequities and inequalities, you know, where would we start?

And I have to say at a I say this a lot. I think we're probably in the, we're probably early enough that we've still got all of the enthusiasm and energy actually, which I hope doesn't go away for obvious reasons. And there's quite a lot of excitement about it, but perhaps expect that at this stage, I guess, as we get into some of the inevitable choices we'll need to make, um, given that, you know, resources are limited, you know, and limit the extent to what we can do then it might get slightly more difficult. 

MATTHEW: Paul, let's go to the flip side of this which is what what can go wrong with this model or perhaps more specifically - because you you you you deal with this really well in the report - sometimes people expect unrealistic things from group models, don't they?

PAUL: Yes, that's right. And I found a number of cases in a number of systems where, being blunt about it, people felt quite forced into getting together. It was a bit of a sort of shotgun type, marriage type arrangement. And even they couldn't articulate exactly what the purpose was of doing it, other than other people were doing it around the country, and it, and it, you know, it got that sense that there was a momentum and energy behind, behind doing it.

And I certainly spoke to a couple of trust leaders who, who said they felt as far as the system was concerned, once they'd made that difficult decision to bring the organisations together to work more closely together, that they'd solved the problem because they then handed that problem over to this new organisation where the the warring or the tense parties were in the same room and they would sort the problems out and of course, a lot of the issues they're trying to address - the things that Stacey so eloquently talked about, you know, her own system - you know, need a lot more than, than organisations coming together to sort them out.

One of the things I talk about quite a bit, and I, and I think, you know, again, what Stacey said, I, and I, I spoke to Stacey during this piece of work, what she has is a real clarity of purpose. And I think one of the things that, that in order to overcome some of those, those difficulties are, are really knowing what you're going to do and why you're doing it.

And I know it seems crazy to say it, but I, but I think in some cases that, that wasn't altogether clear. There were sort of more vague notions of, well, we'll save money by sharing board costs, or we'll make decision making less complicated by having fewer people in the room. All of which may be true, but they're not, they're not fundamental in delivering better care for, for communities that really need it.

And some of the skeptics I spoke to pointed out a couple of things which I think are really important to think about. There is almost no academic research on these sort of models. Um, I think that's something we're missing and I think we need some of that. But where there is research is on mergers. And the, the research on mergers tends to tell, not give us very encouraging results.

It says mergers often don't achieve the objectives they set out to do. And these models are not mergers, but they, but they are pushing in that direction. And I think people going for them have to satisfy themselves that they're not going to fall down. You know, I do think that's an issue that the, the evidence doesn't always support people getting the benefits out of these, these models.

I think the other one is that. That the reality is a lot of smaller NHS trusts, particularly specialist ones, but not only specialist ones, perform really, really well. You know, they've got great staff surveys, the access they give to patients, the quality of care is superb, they get consistently really good CQC results, good staff surveys, all of these sorts of things.

Yet there is pressure on them to join with other larger organisations to make a more sustainable system based provider. And I think when considering going down this route, it's really important to honestly look at those, those issues and make sure that at the very least, some of those risks and concerns are mitigated in the, in the plan.

And I suppose one of the benefits that shared leadership models, group model, whatever you want to call them, have over simply going for a merger is that they give one a chance, often over several years, to test out some of those things about, culture and about delivery and about performance and how it's going to improve by working together before making that final commitment.

If that indeed is what they want to do to a merger, which some do and some don't. 

MATTHEW: Thanks, Paul. So Stacey, you, you inherited this kind of group model, but I'm interested, what do you understand as the kind of origin story of the decision to do this? And how important has that been? Is that still now in terms of the way in which you continue to develop the relationship?

And I'm particularly interested in the role of the board and of your chair in all of this is something that, that Paul says a lot about in the report is the importance of the chair and recognising the need to support chairs when they go on this process if indeed you're kind of moving to a model with a single chair.

STACEY: Yeah, so I think it was a long and pretty tortured history to be honest Matthew, so say the, you can find things documented in the NHS about the two South and North Tees Trusts coming together, you know, 10, 15 years ago. And if you like, the joint chair was put in, it's nearly three years ago now, because all other routes had failed to make it happen.

And there was genuinely, because I picked this up in my due diligence, when I was thinking about the role, there was genuinely this sense from NHS England, you know, and others that the two organisations, you know, had failed to take those opportunities. And there was a lot of frustration about that. If people were, you know, people were quite open and honest in sharing that.

And I think the chair's just done a blog actually for the Confed. So you'll be able to, you'll be able to see some of their reflections. But if you speak to them, I think it was really hard. So I think they were trying to, it took a good couple of years with the support of other external colleagues to get into the space where colleagues would start doing some work on, if you like, the partnership agreement, which is what underpins the group.

And in, and in truth, I think in this part of the country, the, when the integrated care boards were kind of coming about. Sam Allen was appointed to be the ICB chief exec in these parts. And I think it was really when Sam came in and you had, you know, somebody who was a, a bit more local who could provide a bit of support to the chair, that they managed to start to make some progress, but it wasn't universally supported by everybody at a board level, and it's well documented, so I'm not putting things into the public domain that shouldn't be there, but you know, for instance, in one of the organisations, all bar one of the NEDs resigned.

You know, governors, et cetera, so you, it really was a, a, a choppy, I think is a polite way to describe it, process to get there. What underpinned that interestingly, and what I think people kept going back to, was that there was always quite strong clinical support for it. So this sense of, actually, Clinicians who work in the organisations, if you like, who sometimes feel like the poor relations in the North East, to the North of the North East patch, could see that this was getting in the way.

And it was described in one of the reports as the clinicians kind of losing patience with their chief executives and teams for not seizing the opportunity. So that's kind of its history. So its history is long and thorny and I suspect not dissimilar to some of the things that Paul's described and some of those conversations.

And then the thing that I think they did that was fundamental to help the chair, and I certainly feel I am benefiting from directly, is once the decision was made, and they'd been through all of those things, they sought the support of Alwen, who used to be the chief exec in Barts, to really work with the board and executives to say, look, in a year, you're coming together, You will have a single chief executive.

How do you want to show up? What do you want that to look like? And I think then they really made quite quick and strong progress on, I say, the partnership agreements. So that's kind of its history. You know, it hasn't all been hearts and flowers by, by any means. It's been quite challenging, to say the least.

MATTHEW: Paul, we're slightly running out of time, so I'm going to ask you to, to kind of condense two things really in, in, in the next answer, which is partly, what are the, what do, what do you see as being the kind of success factors? You're, you're far too subtle a thinker to suggest that there's, it's, this is simple, but what, what seemed to you to be the most critical success factors and then link that Paul to picking out two or three of the recommendations in your report following on from what Stacey has just said about how particularly at a national level we can better support the decision makers and then support the group models as they emerge.

PAUL: Yeah, thanks Matthew. So, uh, briefly, uh, the key success factor for me is, is this, is being, is knowing yourself when you embark on this and by yourself I don't, you know, don't just mean the chair and chief exec, but the board, the system, the, the people who are the agents in making all this happen is be that very, very clear about the, the, the purpose and the objectives, and that you are gonna be engaging in purposeful activity to meet them.

Because I and I, I, I know that sounds phenomenally basic, but you'd be surprised by how often that didn't appear to be the case. And take a sceptical view, you know, challenge yourself with all of the, the, the, the small sceptical perspectives that I referred to earlier. And I, and I think that quality of thinking at the beginning of the, the process is, is really, really important.

Stacey, and you touched on this. I, I, I do dedicate a little bit of the report for championing the role of chairs, because I think chairs are often the first shared leader put in place and they're not given good enough support. And I, I think chairs need to be supported better generally. I spoke to a couple of very experienced chairs, but they described having to make it up as they went along with a limited amount of support.

And I think, I think that is a problem. To come to the second part of your, your question. So it's already been mentioned by Stacey, but I, I think the regulators do need to catch up. They need to understand that this is now a major organisational model. And when regulating it, they need to understand that that actually has different implications about how you do things like well led reviews and inspections, how, how CQC type inspection reports are put together to actually recognise the different histories and parts of the organisations that come together, the different roles that people play that are not necessarily statutory board roles.

And I think the regulators are not caught up with that. At NHSE level, I think my, my view is that all of the governance frameworks which are written, the code of governance that the, you know, board secretaries live by for, for boards is all written for individual organisations for, for trusts just working on their own.

And chairs and chief execs described to me a really difficult process that they had of actually almost reinventing all of this from scratch because there's no national good practice or guidance available to them. Of course, people get together in the sort of networks that Stacey described and do it informally.

But I think NHS executive, if they think this is a good thing, and if they've commissioned the evidence to tell them that it's a good thing in certain circumstances to get together in this way, it needs to be supported better by having good model constitutions and frameworks, which make it work and make it work legally and, and limit the amount that organisations have to reinvent this themselves. So those are a couple of the recommendations at least a national level that I've come up with. 

MATTHEW: So thank you again to Stacey Hunter, to Paul Roberts and to Chris Smyth for joining me this week. But we're going to finish off this episode with a Health on the Line first. As some of you probably know, a big part of my work here at the Confed is getting out on the road to visit NHS leaders and their trusts and their systems around the UK. I love doing it, it's absolutely essential to help me understand what's going on out there in the system, to see best practice first hand. But as I meet all these leaders, usually in person, sometimes virtually, I had this idea why not capture some of their expertise for Health on the Line and also, well let's find out a bit more about them as people. That's the idea behind Leader in Six, a brand new monthly segment here on the podcast.

It's a very simple premise: I have six quickfire questions which enable us to get better acquainted with the people who lead our health service. So, for our inaugural Leader in Six, I caught up with Zina Etheridge. She's Chief Executive of the North East London Integrated Care Board. 

Well, Zina, here's your six questions. First of all, what's the most pressing issue for you right now? 

ZINA: Money. 

MATTHEW: That's simple. Uh, I could ask you more, but that's enough. 

ZINA: Money, money, money, money, money, if you want more. 

MATTHEW: Yes. What is the area of improvement or innovation in your system that you're most excited by? 

ZINA: So right now, um, the thing I'm most excited about is our St George's Health Wellbeing Hub. It is a brand new building which co locates, brings together primary care, some hospital services, a new frailty pathway for outer North East London and the voluntary sector and some dialysis units slightly coincidentally all in the same building so that we are starting to break down the barriers between different organisations and starting to get more holistic and joined up care around some of our residents with the highest needs.

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

ZINA: So, my name is Xena, obviously. I'm the oldest of four children. My parents decided after I was born that once they'd started with Z that they couldn't stop, so my brothers and sisters names also begin with Z.

MATTHEW: Oh, tell us them. 

ZINA: Zeb, Zach and Zania. The last one, I'm pretty sure, is just made up. 

MATTHEW: Fantastic. If you were NHS King for the day, or Queen for the day, what's the one reform you'd introduce? 

ZINA: I would hardwire funding to communities, primary care and, in particular, into making integrated working in neighborhoods a reality.

MATTHEW: Great. Who is the health service or other leader you most admire and why? 

ZINA: I'm going to choose other leaders and I'm going to cheat and have two. Um, the first one, um, is a woman called Beverley Tarka who has I think just retired. Um, she's just been the president of ADAS. Um, she was the director of adult social care that I worked with in my last job, running a local authority.

She was ADAS's first, um, black female president. Um, and from her, I learned more than anybody else about the vitality of working in a strengths based way, really understanding the strengths you've got in individuals, in families and communities. And my second is, um, former Cabinet Secretary Sir Gus O'Donnell, who I worked with when I was a civil servant, for his mantra about both values led leadership, but also enabling anybody who worked anywhere near him to operate at the top of their licence.

And his mantra was, um, ask, uh, forgiveness, not seek, don't seek permission. 

MATTHEW: I worked with Gus as well and it was, uh, he was great fun to work with. 

ZINA: He was. 

MATTHEW: Um, finally, what are you watching, reading, listening to at the moment, podcast, box set, that you can recommend to other people? 

ZINA: I'm really rubbish at this question because I don't watch television and I don't have the concentration span for film, um, the book, the two books that I've just read that I would recommend to anybody are Paul Johnson on Follow the Money. Albeit it's a slightly depressing read, but I think, you know, actually, if you work in public policy, you should read it. Um, and for lighter relief, um, Javier Marías, any of his books, but particularly, um, Tomorrow in the Battle, Think on Me. 

MATTHEW: Great. Thank you very much. 

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