Matthew Kershaw: When we talk about a backlog, we're talking about patients, people who are waiting

Matthew Taylor

Hello. Welcome to the third Health on the Line. Thanks again the positive response to episode one and two with Rob Webster, and Ifti Majid. If you like the show, please tell other people or leave a review in your podcast app. In our next edition, I'll be heading Northeast to speak to Fiona Adamson, who's chair of our Primary Care Federation Network.

But this week I'll be talking to a leader from just down the road, Croydon, to be exact. One of the characteristics of the NHS over the coming period will be the need to deal with the continuing impact of COVID-19, as well as addressing the major backlog of care that has built up. This is the reason that we and our sister organisation, NHS Providers, have been saying that the recent allocation of government resources for health may not be enough to do both jobs. But in Croydon, they've led the way in thinking about how simultaneously to address both these challenges. Let's find out more.

I’m delighted to be joined by Matthew Kershaw, chief executive of Croydon Health Services NHS Trust and place-based leader for health. Hi Matthew, how are you?

Matthew Kershaw

Good morning, Matthew. I'm well, thanks. How are you?

Matthew Taylor

I'm fine. I've just done my Cold-Water swimming, but I forgot my goggles, so it wasn't very pleasant. But you haven't done your running today, have you?

Matthew Kershaw

No, not yet. I'll be going later. I'm on a run streak and I'm about 410 days consistently running, so I'll definitely be going later.

Matthew Taylor

It's funny this kind of addiction that one gets to physical exercise. How do you think you would cope if you got an injury and you weren't able to run for a week?

Matthew Kershaw

Good question. I think I find it really difficult, to be honest. I'm sure I'd find a way of trying to struggle on for as long as possible, because I do find it a really important part of mindfulness for the day.

Matthew Taylor

The thing is, I think it is really important if you're a leader, that you attend to your own wellbeing because if you don't feel good about yourself, it's harder to behave well towards other people, isn't it?

Matthew Kershaw

I completely agree. These jobs are difficult jobs and they're important jobs, and you've got to be true to yourself, to put yourself in the best position you can to do those jobs each day. And so, yeah, I think it's whatever it is that you find that does it for you. I think it's important that you maintain that.

Matthew Taylor

So you talked about the challenging nature of the job. How are things in Croydon right now?

Matthew Kershaw

I mean, we're at the start of another period of real challenge and we're seeing significant emergency pressures right across our system. I’m place-based leader for health here in Croydon, so I have a view on primary care, our community and acute services that we run in the trust and all aspects of that are seeing significant emergency pressures. And of course, at the same time, we're trying to deal with the elective care backlog as well as supporting our staff, managing the vaccine programme and transitioning to more formal integrated care arrangements.

Matthew Taylor

And Croydon has been, I mean everywhere has been, hit hard by COVID-19, but Croydon has been really hard hit by COVID-19. Presumably, you've still got quite a few patients in hospital. But overall, it's been a particular challenge in yourpart of London, I think.

Matthew Kershaw

That's absolutely right. We are a very, very diverse borough here in Croydon. We're large. We're nearly 400,000 people, over 100 languages spoken in the borough and significant differences in those populations and significant elements of deprivation as well. And so I think all of those things combined meant that Croydon very much got hit hard in both the first wave and the second wave of COVID-19. And we're now in a situation of pretty steady but significant levels of COVID-19 so we've had between 50 and 55 — 60 inpatients with COVID for the past month or more. And the prevalence in the borough is similarly, 250 to 300 per 100,000. It's a big number of people who are now with COVID-19 when 18 months, 19 months ago, we didn't have that at all.

Matthew Taylor

And tell me about the challenges of the vaccination programme, presumably you've had to do a lot of work to reach out in such a diverse community to make sure that the vaccine message and the vaccination itself gets out across that community.

Matthew Kershaw

Yes, very much so. I’m the senior responsible officer (SRO) with a colleague from the South West London CCG for the South West London vaccination programme and between us and our fantastic team, we've done a really good job in getting the message out around vaccination. The vaccination rates for our population across south-west London, relatively speaking, are very strong and we have used local leaders, whether they be community leaders, particularly in Croydon, the churches, the mosques such like.

We've also used Crystal Palace Football Club, for example, which obviously has a strong connection to our population and we're now going into the colleges. We're waiting to hear, of course, about the 12 to 15 year olds and are planning now for that eventuality, should JCVI go forward with that.

Matthew Taylor

And what do you think, Matthew, that we've learnt from the work we've had to do on vaccination in terms more broadly of the question of reaching out to those parts of the population who may not be using the health service in the way that we might want them to be, in the way that they might need to be.

Matthew Kershaw

I think the point that you raise is really interesting. I think what the vaccination programme and COVID-19 has shown us is that part of our job as a health service is to not say, well, “this is how it's going to be.” You have to fit with it, but actually to think a little bit more about the way that the populations are and fit our services to the population. Because they're the population in need and we shouldn't be running the service for our convenience that they then have to work to. It should be the other the way round.

Matthew Taylor

I want to come back to it to some of those themes, slightly later, Matthew. But I wanted to first explore the decision that was made last year to set up an elective centre in Croydon University Hospital, something that enables you to combine recovery of elective, and indeed cancer services, with responding to the second wave of the pandemic. Tell me about the background that led to that decision to set up that elective centre in the hospital.

Matthew Kershaw

We could see the situation with COVID-19. When COVID-19 first hit, our whole focus, not just in Croydon, but across south-west London where we work very closely and collaboratively with our colleagues, our focus had to be on responding to something that we’d never in our lifetime experienced before, and all hands were to that particular challenge. But also there's a lot of patients who have elective care needs, and our job isn't just to be responding to COVID-19.

We always described it in Croydon as we're not the coronavirus health services we're the Croydon health services, and that was sort of the start. So if that's what we're saying, we've got to make that good. And so one of our clinical directors, the clinical director of surgery, Ms Stella Vig, came up with the concept of sort of separating out or separating off part of our site to create the, what we call, the hospital within a hospital and the Croydon Elective  entre was born from that idea.

Matthew Taylor

For me, this is a is a remarkable thing that you've got the second wave rising. I think for most people just being able to deal with that, because it's not as if we knew what was going to happen, how big, how deep that wave was going to be, and at that time you find the headspace, your teams finds the headspace and the ambition to say, no, actually, we can do something about elective recovery by setting up this hospital within a hospital. There must have been some people who felt that. This was too much. This was a strange time to be trying to do something else beyond dealing with this enormous COVID-19 crisis.

Matthew Kershaw

The timeline is we set the elective set up sort of post first wave, as we got into that period where things did calm a little. And then as the second wave struck, we made a decision to continue it. Clearly, people can see that backlog and when we talk about our backlog it's patients, it's people who are waiting for procedures rather than numbers. So there were people waiting, and we felt it was important to do our bit to try to minimise the waits that these folks would have. And so there were people who were encouraging, but there was also some nervousness and some scepticism that we could carry on in the second wave. And of course, we had to make sure that we were creating enough capacity for the emergency work and the COVID-19 work, and that we weren't going ahead with, you know, in inverted commas, very routine patients. I'm not sure, for the people who are awaiting it’s very routine, but you know what I mean?

There are various levels of urgency and priority, so we had to be careful not to go to very routine patients, when people elsewhere were struggling to get in their cancer patients and their very urgent. So we made sure that we were offering capacity to our colleagues across south-west London. So this isn't just a Croydon initiative. There's benefits here right across the south-west of London, which is our integrated system footprint.

Matthew Taylor

So this resulted in this initiative. The hospital within hospital had real impacts in terms of your performance on both elective recovery and getting cancer services back on track. Tell me, in what way do you think the culture that you've tried to develop in Croydon was one where an initiative like this could be could be taken forward?

Matthew Kershaw

You're absolutely right. There's a cultural aspect to this as well, and it's quite a connected place Croydon in lots of ways, and it's not that there aren't challenges and different views across Croydon. Of course there are, but it feels connected. And I think one of the things that have enabled the work that we've done is that we've got an issue here, what can we do collectively to address it? And I think that is part of the culture of Croydon. And one of the things as a leader is you've got to both reflect the underlying culture and build on it and obviously work hard to try to improve it. And that's what we've tried to do. That's what I've tried to do.

Matthew Taylor

And, collaboration is a long game, isn't it? I mean, building those relationships, sustaining those relationships so that at a point of crisis or innovation, they're there for you. So tell us about the One Croydon Alliance, because that goes back to 2017, I think. Is that right?

Matthew Kershaw

It does. Yeah, the One Croydon Alliance is sort of an encapsulation of the desire in Croydon to work as integrated as we possibly can. And we have a local authority, Croydon Borough Council and Acute and community trust and in old money a CCG in Croydon that were all co-terminous. And I often describe this to colleagues elsewhere, a bit like a family. When that's working well, then that's an amazing opportunity, and you can make fantastic things happen.

However, a number of years ago, pre the One Croydon Alliance, there were real challenges in Croydon. Croydon has not always been a paragon of close working, but as you say, back in 2017, there was work done that basically concluded that Croydon has in its hands to do things better for itself, but it has to work together to do that.

Working against each other is no answer. And at that point, to be fair to the people who were there at the time, some of whom are still around our chairman, Mike Bell, at the trust and our lead GP Dr Agnelo Fernandez both have got long histories in Croydon and they, among others, supported this development of what's called the One Croydon Alliance which is the local authority, the health bodies, voluntary sector working together to integrate our services to sort of rub away some of the boundaries between organisations. What the NHS and the broader care system is now trying to do nationally with it, with integrated care systems we think it’s validation of the Croydon approach.

Matthew Taylor

So in the papers, with the settlement for health and the announcement of the social care reforms the government has promised a white paper on integration. So there's going to be more expectation of collaboration between health services and local government. One of the things that's remarkable about the progress you've made in Croydon is that for quite a lot of the time since you set up the alliance, the local authority has been effectively in dire straits financially, hasn't it? So how's it been possible to collaborate with a local authority on the verge of bankruptcy?

Matthew Kershaw

Yeah, I mean, it's not straightforward. I would add, however, at the early part of the alliance, it was elements of the health service I'd say that were probably more financially challenged than the council. So Croydon Health Services, the trust within Croydon, that I’m chief executive of, historically has not had, has not benefited from an easy financial situation itself. The CCG put a lot of work in with the trust to try to help address that, and one of the massive benefits of what we do here in Croydon is we have a joint executive team, so I have the joint chief financial officer who oversees in old money, the CCG’s financial situation, as well as the trust's financial situation.

Now that was ahead of its time. That sort of does rub away at the purchaser-provider split. And I'm somebody who's worked in the health service a long time and have definitely maximised the benefits that the purchase- provider split brought in its early days. But in the current context we are in, I’m in absolute 100 per cent supporter of that being moulded into a different arrangement and that integration coming to pass. So I think the health side has been through its challenges and the council stood by and supported the health teams at that point.

And yes, you're right, more latterly, the council has had a very significant financial challenge. And what we did as a health team was stand absolutely foursquare with them because in a collaboration and a partnership and an integrated way of working, you're only as good as all of each of the partners. And if the council was going to get into a even more difficult financial situation, then ultimately that's going to undermine what we're trying to do for the population that we serve.

And so it was a big decision to make, but we believe absolutely we made the right decision to stand absolutely foursquare with the council and do everything we could to help them. And I think that's borne fruit and has maintained the relationship and allows us now to continue to to push forward. Notwithstanding the fact that it is very, very difficult, their financial challenges haven't gone away and they're likely to get probably more difficult rather than less. And ours in the NHS are not going to get easier either, are they? Despite the excellent settlement that has been reached, the demands are massive and therefore the next few years, financially, is going to still be pretty exacting. But I think we've shown we can work through that and I hope that we continue to do so.

Matthew Taylor

So I already sense a kind of pushback in certain quarters against ICSs, against the new way of working and the kind of suggestion that this will just be layers of new bureaucracy and I want to explore a couple of the ways Matthew, in which you've used collaboration a very focused way. So first of all, the focus on efficiency and quality has been at the heart of what you do. It's not just been collaboration for collaborations sake, there's this very strong emphasis on how can you do things better and how can you improve quality of outcome?

Matthew Kershaw

That's absolutely right. I mean, other people who may be listening to this might have heard me say this before, in which case apologies, but I think it's worth retelling. I describe integration needing a number of things, and it sort of responds to your point that people say, “Well, it's just bureaucracy, really.” And there is a risk that this is lots of, you know, people like me sitting historically in hotel rooms, now on Teams meetings, talking about how they, you know, we run new governance systems. Well, that's not what integration is about.

Integration is about actually doing things differently for the people that we look after, our staff and most importantly, our patients and the population at large. And so you need to have strong relationships. You need to have a vision about what you're trying to do and that's collectively owned. You need to be, crucially, actually making some things different. You're absolutely right. We focused on quality and efficiency. We've focused on trying to provide services that respond to the specific needs of parts of our population. We've got a system called the Integrated Community Networks, which is a pilot of a service which is multi-organisational, focused around a population of 50 — 60,000 people in Thornton Heath, which is one of our most deprived areas and that will engage with the population as much about housing as it will do about their health needs. Because how do you split those things up? We know that you can't. So that's about integration delivering actual change on the ground.

And then lastly, you do need a governance system that keeps you in the right place because you know it is taxpayers' money. It's important that we have a proper governance system around it. But the governance system should be the last thing that we get in place. Not the first thing. And there is a risk, of course, when we turn a white paper over to integrated care that the governance thing becomes the first thing that everybody does. And we've tried hard to keep governance as a central tenet of what we've done. But as a sort of supporting work stream as opposed to the only thing that we're doing.

Matthew Taylor

Another thing which you've kind of referred to is that you're trying systematically to move away from a health system, which is based on incentivising activity to one that focuses on population health. And that's going to be absolutely critical, isn't it, in the medium term if these new systems are to work, it has to be because we're focusing on population health outcomes, not just the amount of activity the health service undertakes.

Matthew Kershaw

That's absolutely fundamental. But, you know, I definitely remember in my early career listening to chief executives at the time, talking about the size of their organisation in beds and in activity as sort of a mark of success. I'm not now saying, they were wrong at that time. That was what was at that time. I was involved in national projects for the department, reducing waiting times. Well, we're back to some of that and the elective centre. But a lot of that was driven by payment by results, for example, and that had its moment.

But were in a different world now and we absolutely shouldn’t be talking about success as driven by the numbers of patients that you treat. It is absolutely about looking at the wider population health measures. And in a population as diverse and in parts as deprived as Croydon, that is even more important because if we don't do that, then we know what will happen is that those inequalities will get greater and the demands on the service will increase to a point at which it will be increasingly difficult for us to respond in any sort of effective way for that population or indeed for a financially viable system for the NHS and care in Croydon.

Matthew Taylor

One of the challenges that we don't talk about often is if this is going to be the way we work, it needs to go way up the system. So you're talking about working with the local authority, you're talking about focusing on housing and employment and issues like this as you think about population health. Yet that's not how Whitehall works. So one of the challenges of this new way of working is that whether it's NHSEI or the Department of Health and Social Care, they need to be collaborating across Whitehall because population health needs to be across Whitehall initiative, not just something that is pursued by the health department and the health service.

Matthew Kershaw

Yes, I would agree, Matthew. I think, you know, there are, of course, differences in the different departments of state and there are differences when you look at the local authority versus the health service. In a place like Croydon, our budgets come down in different ways. They're voted for in different ways, they're governed in different ways and that democratic accountability of councils is different to the democratic position that the health service has. All of those things are true.

But if we're going to properly integrate, then you have to do it starting off at place and neighbourhoods as we're trying to do in Croydon, and we've got a long way to go, we are nowhere near the end of our journey and we will have missteps along the way, I'm sure of it. But we're doing the right thing in the right way or certainly trying to. Loping away some of those historic boundaries, is important, it's necessary, but it has to be done with care because you can certainly rub away things quite quickly in one sense and create other difficulties and problems. So with care. But I would say with clarity over what we're trying to do, I wouldn’t disagree with you.

Matthew Taylor

And I'm a relative newcomer to the health service. One thing that I'm still wrestling with, and I think it may be because it's so different from place to place, but is the relationship between systems and places? So we've talked about Croydon, you and I, most of this conversation, and that's a place. But you've also talked about south-west London. Do you have a sense of what needs to be the relationship between the system and the place? I mean, the only kind of thought I have here is that system leaders need to have a kind of value-adding proposition so ICSs, wherever they are, need to be able to explain what it is that system working at ICS level does that wouldn't otherwise happen?

Matthew Kershaw

Yes. My short answer to your question is that systems definitely have a role. They obviously have a coordinating role between places. They also have a role in supporting and taking forward work that can only be done or best done at a system level. So if you look at workforce, for example, if every single place was sort of putting a little fence around itself and saying, OK, well, we're going to look after our workforce, then there's a danger in that places then become very competitive against each other. And ultimately, that creates less value than a more collaborative, system wide approach. And the same might be true on digital as a as a concept. Estates is another area where I think there is real merit of systems actually doing some things at a larger scale. And then, as I say, there is the role of coordination and system leadership, which I don't think should be undermined at all.

I think the ICS chief execs and the integrated boards and partnerships that are going to be established definitely have a role. What I would say, though, is that needs to be kept as thin as possible with the most energy put into place-based working, because that's where the real innovation and change happens, is in neighbourhoods and places. Because people who work close to, you know, delivery of services know the best way of getting change is by asking the people who are actually doing the work. I say on my staff induction every week you guys are going to come up with the best ideas for how we improve what we do. Not me sitting in my office or me talking to my executive director colleagues. It's the teams out there who are best placed to identify the need for and the ways that we can change to improve. And I think that's true for neighbourhoods, places below systems.

But I would definitely support the creation of systems. But in the way that I've described and my sort of final point on it would be we integrate, sort of, naturally and that's what we're trying to do all the time. But that is not at odds with system working because there are certain things that can only be done at a system level. And if I use an NHS example, I always say to people, the interventional radiology challenge in south-west London is not going to be solved by a place-based arrangement in Croydon, because the only people who are thinking about interventional radiology in Croydon is the hospital because we're the only people who employ those folk. So we need to work with our colleagues at St George’s, at Epsom and St Helier, at Kingston to solve that particular challenge.

So it's about collaborating on a bigger footprint and integrating locally. I think if you get both of those things working well, then that's when you can really, really make positive progress. And that's why I'm so supportive of provider collaboration, one of the new parts of the white paper, alongside integration in places, those two things are definitely not running against each other. We have to find ways of doing both at the same time.

Matthew Taylor

It's been an absolutely fascinating conversation. Matthew Kershaw, thank you so much and good luck for the winter ahead.

Matthew Kershaw

Thanks very much, Matthew. All the best to you to.

Outro

This episode of Health on the Line is part of our new Integration in Action initiative, which brings together podcasts, events and case studies from our members on themes affecting the health and care system. For further insights into elective recovery and how systems are working together, look out for our forthcoming report. And to hear more from Matthew Kershaw about how Croydon are tackling the challenge of elective recovery, sign up for our breakfast briefing on the 30th of September at nhsconfed.org/events.