ICS series: developing a high performing integrated care board

01 December 2022

The Good Governance Institute’s new ICS series of online discussions began with a session chaired by GGI principal consultant Fenella McVey, who led a conversation exploring the challenges and opportunities for engagement in integrated care systems.

Cedi Frederick on the importance of restoring faith

The first speaker, Cedi Frederick, has had a long and varied career in senior roles across multiple sectors, including housing, social care and sports as well as health. He is currently chair of Kent and Medway integrated care board.

Cedi said: “I think that one of the biggest challenges we face is to restore faith, trust and confidence in the NHS. Speaking from a personal perspective, I know that many colleagues from the voluntary sector, for example, who we will absolutely rely on going forward to work differently with us, and also across local authorities – including elected members – don’t really trust the NHS and we’ve got to do the best job we possibly can to establish new relationships and build the trust we need to work together collaboratively.

“Having worked in the voluntary sector and social care for many years I carry a huge frustration that making any sort of meaningful contact with the NHS and influencing its thinking at a local level was almost impossible and many of the people I’ve spoken to in Kent and Medway feel that getting their message across – being heard and listened to – within Kent and Medway is going to be really difficult. So we have a real job to do to change how people view the NHS and its systems and to bring people along with us.

“I continue to socialise the idea that we’re developing in Kent and Medway that we’re starting a movement – simplifying what is an extraordinarily complex eco-system into something that everyone can buy into. That’s quite a big challenge when people have different perspectives – they’re fighting for their own survival in the voluntary sector, for example. Organisations that haven’t really engaged with the NHS before – housing departments, business, the police and other statutory agencies – who I think all need to make their contribution towards working together to deliver the four big objectives we’ve been asked to take forward.

“And we must balance that with our short-term must-dos. We’re facing an extraordinarily challenging winter because of the cost-of-living crisis and everything that arises from that. […] I believe fundamentally that integrated care systems and the vision we’re now developing is the future. I think it’s the only game in town. We understand now that 20% of people’s health sits within the health system, the remaining 80%, the wider social determinants, are within areas that we cannot directly control but we’ve got to get the people who do control those areas – housing etc – into the conversations that many of them have not really taken part in before.”

Rob Webster’s five points

Our second speaker was Rob Webster, chief executive of the West Yorkshire ICS and an NHS leader for many decades, as a chief executive of trusts, and working on policy as part of the prime minister’s delivery unit, and former CEO of the NHS Confederation.

Rob said: “We should start with asking what is an ICS? Because there’s a battle for the soul of what they are at the moment. I’m clear that the system is the system – it’s made up of the organisations within it and we all have a role to play, whether that’s third sector NHS councils or communities themselves.

“You need to have somewhere to live, someone to love and something to do to be well, which goes beyond our remit but at least some of it is the remit of our partners.

“The second point is that to be high performing you must never lose sight of purpose. What I’ve seen is that where there have been high-profile failings in organisations it’s because people lost sight of why they were there. In West Yorkshire, which is a complex system with 2,500,000 people, ten trusts, six councils, hundreds of general practices, thousands of third sector organisations, we always focus on purpose. We’re here to improve outcomes and deliver those four things which are now on statute. If we’re going to do that, we have to be clear about what underpins our work together and how we behave together.

“The third thing I wanted to reinforce is that high-performing organisations are really clear about the rules. We’re not on day 100, we’re on day 100 plus six years. Because ICSs have been around since 2016 as STPs, and if you look at what we’re building on, in West Yorkshire we’ve always been very clear about the arrangements between us all, in terms of the governance – one of our values as a system is that we value good governance, openness and transparency, and if you don’t have these you will not be high-performing because people will not be telling the truth about where they are in the system.

“You also have to have the right behaviours. We’ve all worked in places where people say one thing and do another. We’ve been crystal-clear that the way we behave and our relationships in a distributed leadership model is as important as those rules. And the relationships are underpinned by a set of behaviours that were co-produced by all the leaders, to say ‘what’s it like here when we’re at our best?’. We have a set of behaviours that are linked to the values – things like our decisions are motivated by shared purpose, we have empathy with staff and people, we collaborate in all we do, we suspend our egos in service of each other, we see diversity as a strength. We’re able to think critically and conceptually, we’re agile in our governance and the work that we do, we’re willing to share risk, we share power, and as a leader I’m happy to retain accountability and give other people authority.

“The last thing I’d say is that if we want to be high-performing we have to be honest, and we have to keep the person we’re there to support in the room with us at all times. Since we started as a statutory body, our board meetings have been preceded by a listening session with people affected by the conversation that day. Not a scripted patient story, but a set of people who are going to tell us how it really is. Good and bad. The board is there to listen and absorb and consider.”

The Sheila test

Rob continued: “Our work on race equality and the impact of Covid on inequalities led to a commission, which led to a range of actions on commissioning, workforce, leadership and the wider determinants. Those are standing items on our integrated care partnership, which meets in public and has been meeting for four years. There are a series of measures we’re looking at, to make sure we’re delivering against that – but the biggest measure is the Sheila Test. When we launched the review, everybody went from being very sceptical to being hopeful. At the end of the session to launch it, a little voice appeared – Sheila from Chapeltown – saying ‘I just don’t believe you. I’m not going to see this in Chapeltown in north Leeds.’ So we said, when Sheila sees it, that’s when we know it’s working.

"This is a really exciting opportunity for all of us. The reason we have integrated care systems is because the needs of people have changed. In a modern health and care system we have to meet the mental, physical and social needs of people because people have all sorts of issues that they are successfully living with most of the time. The average person admitted to hospital has three things they’re living with. What we’ve got to do – and what I hope the Hewitt Review does – is resist the temptation to put our previous experiences and thinking onto integrated care boards. This is not another intermediate tier, it’s fundamentally different from everything that’s gone before it and if we design it properly it will deliver things we’ve not been able to achieve before.”

Sarah Morgan: why policy implementation fails

Our third and final speaker was Sarah Morgan, chief people officer at North Central London ICB, who previously worked at Guy’s and St Thomas’, at mental health trusts, and the Dept of health a Social Care where she led the work on the Dalton Review.

Sarah said: “I did my masters on why policy is implemented in a different way to its intention about 15 years ago. And it was because of social constructs. People who have been in a system a long time said ‘Oh we’ve been here before. It’s just like X or Y.’ And that’s the risk – that we think we’ve seen it before. But we haven’t seen this before; we’ve not seen an integrated care board before and we’ve never had this opportunity in the way we do now. It’s something we have to grasp and keep an open mind about what we have to do differently.

“My organisation is five CCGs that became one during the pandemic. So the staff went into a merger without really being able to talk to each other about it. Then we went into another merger into the ICB, and we also took on another side of the organisation while everyone was still predominantly at home and that’s a really interesting place to be, trying to get your arms around an organisation, create a new identity, help staff transition from what was a CCG that they understood into what it means to be an integrated care board organisation.

“Somebody used the phrase ‘statutory start-up’ and I think that really sums it up. We’re in this phase where we have a new board with a wide membership who are struggling to understand the role of the organisation and the 800 people who work there. How does that governance work? We’re still on a governance journey. I’ve already felt not valued – my staff are not entitled to the flu vaccine and the Covid vaccine and that’s left a staff group who are really confused, and morale is quite low. Our ambition is to make our organisation a great place to work so we can serve the population.”

Also overheard during the session

“Patricia [Hewitt]’s review is welcome. She is on record as saying that ICSs are all about place. We will see whether that is still her view. I do worry about the governance being split between a partnership board and a more NHS-centric, more executive care board. It does not make for natural cohesion.”

“Given the stretched resources and workforce challenges across systems, it would seem that pockets of activity/resource/funding might sensibly come together at ICS level to optimise quality of service and efficiency. How might that be achieved given the organisational boundaries and as suggested the egos that might get in the way of true collaborative working?”

“To me the change to the clinical and care models will drive a need for our people to transform their skills, capabilities, behaviours and ways of working in order to deliver that new model. This skill set doesn't really exist at the level we need it to within the HR and OD community and actually tends to be clinicians who have formed an interest in workforce and OD over their career. We need to have support running alongside these clinical changes to actually change how our patients and population experience care in the future.”

“It’s a mindset change hospitals stop seeing themselves as repair centres and instead as anchor institutions with a responsibility to keep people well too.”

“The current challenges faced by ICS partners together require strategic solutions and so my concerns are about the short-term nature of the central diktats forced on systems which could absorb 80-90% of time. Feel we have to remain focused on more strategic and innovative solutions to really make a difference to population health and wellbeing and outcomes.”

“Surely, the key word is integration. For the first time we have structures for health and care which bring together all relevant parties, and on a scale which can recognise local priorities. There will be many difficulties in building the trust and agreeing the priorities, but the opportunity is remarkable and one not to be missed.”

Look out for details of more discussions in this series in the new year on our website events page.

Prepared by GGI Development and Research LLP for the Good Governance Institute.

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