NHS Shropshire, Telford and Wrekin is one of the smaller health systems in England, covering half a million people across a semi-rural setting. Chief executive Simon Whitehouse gives an overview of the ICB in an interview with Healthcare Leader’s editor Victoria Vaughan
Victoria: What are your top three areas of focus?
Simon: Workforce, workforce and workforce. Whichever part of the system you look at, we’ve got challenges in our workforce, and there’s nothing magic or rocket science about this; it’s about how we retain the staff that we’ve got, and how we recruit in a way that increases the net overall workforce: not moving them from community trust to acute trust to general practice.
V: Does the answer lie in hiring from overseas?
SW: That’s been one of the areas that Shropshire, Telford and Wrekin has done relatively well at, and needs to continue but we have to look at all elements of workforce, recruitment and retention. First, we have to shore up and we have to make the jobs, jobs that people want to do. We have to recognise how hard people have worked, the challenges they’ve faced, the pressure they now feel under in terms of waiting lists, backlog, demand, and the impact that has on our front-line staff as much as it has on our managerial, admin and support staff. And that’s taking its toll.
You then play into that the cost-of-living crisis in a rural area, where you’re having to ask people to travel to do visits at home or to get to community centres. We’ve got a double whammy here in terms of that. And then trying to compete in the salary market, in terms of domiciliary care – If we’re looking at this from a system perspective, not just from health. Aldi and Lidl and others… I know you will have heard this elsewhere, but it’s genuinely the case, we can’t compete against their salaries.
V: Is there anything you can do besides salary to make these jobs attractive?
SW: We have to look at all the options. How do we properly look at what our staff offer is, in terms wellbeing. How do we look after our staff? How do we make the jobs doable and see the recognition and the value they add? How do we make sure that the working conditions are as good as they possibly can be, given the limitations around capital estates etc? How do we build a real sense of team, so that actually people do not feel they are in it on their own, but are part of a team and can see where that team contributes to how we function as a system?
And what can we do around the edges, in terms of mileage or supporting staff or hardship and in that space? So the practicalities of local flexibilities, against the national pay system, and just making sure, we don’t have unintended consequences of destabilising somewhere else by trying to do the right thing. We’ve worked to increase mileage for a short time period, across all of our providers so that we can just recognise the increased cost of fuel that people are having to put in the cars.
V: Are you aware of any food voucher offers in your ICB area?
SW: Those are the conversations that we [started in August] with chief execs in terms of what’s the concerted effort that comes in over the autumn and over the winter. Interestingly, there’s a lot of conversation around how we target this at the low pay bands, and of course that’s important, you would never get me disagreeing with that at all. But we’re seeing band 5s, band 6s, because of their personal circumstances, in as much hardship and as challenged, and actually if we’re not careful we do everything at 2s, 3s and 4s, and we miss the hardship that sits in 5s, 6s and 7s.
V: Aside from workforce what other areas are a priority?
SW: The recovery piece in terms of the backlog, and the whole demand issue that exists around this. It’s not just the two-year waiters, it’s also some of that hidden demand that’s in general practice, that’s in community services. Speaking to general practice, one of the things they’re saying is, ‘Simon, look, all the focus is on the long waiters, appropriately so, absolutely, no issue with that. However, we’ve got those that didn’t come forward during Covid and are now starting to present and say, “I’m unwell”, but are probably more unwell because they waited.’
We’ve also, in general practice, got the issue of those patients who are on the waiting lists coming back to general practice, so creating double demand. And that’s absolutely fair and appropriate for those individuals, but we’re absolutely still playing catch up in that, and then we’ve got the mismatch of our demand in general practice versus the activity that’s there.
General practice across Shropshire, Telford and Wrekin have done an absolutely sterling job, both during the pandemic and during the vaccination programme, and continue now to offer significantly more appointments than they offered previously. And still we can’t match the demand that’s coming through the door and through the phones.
I sat with a GP practice last week and they showed me their pattern of calls on a half-hourly basis, versus the number of call handlers, versus when they ran out of appointments, and how many appointments they were offering compared with this time three years ago.
You can see that complete mismatch at 8am, 8.30am, 9am, then it settles down by mid-morning, but by then there’s no longer the appointments to match even the reduced number of calls that are then coming through. We’re then driving even more to ring back the following day at 8am and try and be fastest finger first.
V: What’s the ICB’s role in supporting primary care?
SW: The ICB’s role with general practice is fundamental. The reason I signed the letter [that came alongside the Fuller report] was not just because I felt it was important that my name was on there and I was not the 42nd that wasn’t on. I signed it because we have to get side by side with general practice, you cannot have an integrated care system [ICS] without strong and sustainable general practice being a central, key component to it.
We have to pick up from where CCGs were, and get to a point of, what’s the development plan for general practice, what does that look like and how do we work with you to get to the right place around the model of general practice?
I’m not even talking here about what the national team can do about negotiating contracts. What can we do on the ground? How do we make best use of primary care networks (PCNs), recognising that they are a building block, they’re not the solution to everything and nor are they the silver bullet, but as a part of general practice at scale.
We’ve got to use the DESes and the LESes and the discretionary money in the right way. We have to make sure we’re using the right IT, and we’ve got to get the comms right with the local communities in terms of what we’re trying to do and what does that look like. There’s no quick fix, though, to this in terms of that mismatch of phone call, access, demand piece.
V: Are you working on a primary care development plan?
SW: Yes, so I’m very careful about language around this. I talk about general practice when I mean general practice. When I talk about primary care, I’m talking about community services, wider clinical teams, and I think it’s important that we’re careful around language in that regard. Because you can do a broad brushstroke of supporting primary care whereas I think we also need a specific focus on what are we doing to support general practice.
V: What’s you’re view of PCNs role in primary care?
SW: PCNs are a building block and are a part of the offer. I don’t think they’re the be all and end all. I think we have to start at the individual practice, so part of what we’re talking about is what do we really mean by integrated teams? How might we use the additional roles work, our community service provider, our mental health provider, general practice and our local authority, to properly think about what it means to look after that community, that cohort of our residents. What, then, do we do with population health? Because the key bit we need to get to in this is that preventing piece of those individuals that are likely to reach crisis. How do we get to them before they reach crisis? There’s a lot of focus on the top of the triangle of need, and we need to be working further and further down that triangle of need.
V: Are you planning on producing a package of what the ICB will do for general practice?
SW: I think we absolutely have to, but it has to be co-produced with general practice. So it’s not a ‘What can the ICB do for you?’ It’s what can general practice with the ICB do to better meet the needs of the population by creating sustainable general practice.
V: Have you got good engagement with your practices?
SW: Since I started, at the beginning of this year, and formally took up the role in July, I have been genuinely impressed with the level of engagement and the conversations I’ve had with general practice across Shropshire, Telford and Wrekin. They’re struggling, and they’re challenged, but they are working really hard and want to work to see what can we do differently and what can we do better.
V: What’s the relationship like with your 51 practices and your PCNs?
SW: I’ve been to locality meetings, which is all 51 practices, I’ve met with PCN clinical directors and I’ve met with the LMC. We have a morning call every Wednesday for interested GPs, it’s not an invite only, it’s interested GPs, me, a couple of my directors just asking, ‘Right, what’s going on, where are we up to?’ So that’s a more informal bit, so you’ve got to do it at a number of levels. But let’s be really clear, when I was in Cheshire, I was Director of Primary Care, so I understand general practice, and I understand the value of general practice, and I understand what happens when you get it wrong with general practice. So my core driver, as an ICB chief exec, is to partner alongside and work with general practice. It’s an absolute no brainer, it’s in my core modus of operating in terms of how I will function. I can’t do this without having a relationship with general practice.
V: How are you approaching health inequalities in your area?
SW: What the vaccination programme and what Covid has mobilised and shone a spotlight on is [that we need to do things differently]. The conversation we’ve been having around one of our community diagnostic hubs is where would we best locate that, to better improve access for those populations that might not have the ability to get to some of the diagnostics previously? I’m not sure we would have had that sort of explicit conversation previously, in quite the way that we’re having this time. That’s one small example, and so if we can get, faster diagnosis, if we can do the education around , ‘If you’re worried about cancer…etc. we can get you into that pathway quicker’, then actually the outcomes will be different, and that’s not five or ten years down the line. [In regard to] health inequalities, everybody does the Marmot bit of education at home, job and exercise and choices. That’s really important.. But we’ve got to do that alongside developing our services and enable access to our services to be more targeted now, because if we can do that in the right way we can have a bigger impact, actually.
The uptake of the vaccination programme enables us to understand different use of healthcare in our population in a way that we probably knew was there, but didn’t look at in the way that we’re starting to look at now. Both of my local authorities public health are amazing, they are really on the front foot in terms of that population health piece and the outcome framework and the understanding our communities.
When it comes to our integration strategy, the first bit of that needs to be built on our two health and wellbeing board strategies. Let’s not think that health suddenly has come up with a new idea in this space. I think health needs to show a little bit of humility in this space, and needs to recognise the work that local authorities have been doing, and come and say, ‘How can we contribute to that, and if we can work together on this, can we deliver an integration strategy that’s much more than just saying health’s now got a new idea, let’s have an ICP’.
V: How are you managing the deficit alongside other priorities?
SW: It’s our inheritance. It’s not the finance that keeps me awake at night, it’s the workforce bit that keeps me awake at night. But it’s linked, because we have not got a really stable workforce, we’re spending more on agency and bank staff. That skews our finances. Because we’ve not got a stable workforce, we’re having to find ways to compete differently. That costs us more money. Because we’ve not got really strong integrated care and strong community teams wrapped around general practice, we’re duplicating on diagnostics spends. The bit we’ve got to do is be absolutely unremitting on our financial expenditure, but do it in the round. If we just chase the money, we’ll make bad decisions and we’ll get into the wrong place. We’ve got to give people the confidence that we are targeting the money in a way that will deliver more efficient and more effective care.
It has been nearly three months ICBs officially took over CCG’s statutory duties that were in place in the NHS since 2012, and there remains much to work out. Here, Healthcare Leader looks at how ICBs’ relationship with primary care will strengthen the system.