Graham Urwin, chief executive of Cheshire and Merseyside ICB, tells Healthcare Leader’s editor Victoria Vaughan about his future plans for the ICB, reflects on the Letby case and violence towards primary care staff.
Victoria Vaughan: What are the unique characteristics of your ICB area?
Graham Urwin: We serve a population of about 2.7 million people and have over 350 GP practices, 51 PCNs, 590 pharmacies, 300 dentists and 230 opticians. We recognise nine places within our patch, all coterminous with the nine local authorities of Cheshire and Merseyside, and each has a place management team.
Collaboration is really important to us. An example of that is the elective recovery program. We want to reduce the size of waiting lists, clearly, but there are also some transformation objectives, such as having fewer follow-up outpatient appointments and having more outpatient appointments set up on an advice and guidance basis. It’s really important that we don’t allow that to simply be a transfer of work from secondary care to primary care, or for primary care to find they have nowhere to go with a patient.
A piece of work undertaken by Dr Jonathan Griffiths and others effectively reached a strategic concordat between primary care and secondary care to set out how we’ll work together with those handoffs and the transformation of services.
We let the acute trusts lead the transformation of outpatients, but we put a GP right in the middle of it to make sure that primary care influences the design of that program.
VV: What sort of an impact does the work you’ve done the interface between sectors have on patient transfer between primary and secondary care?
GU: It sets out how we expect people to work together and resolve issues as they arise. The relationships between primary and secondary care on our patch are very good but there will always be pockets where they won’t be. Having that framework signed off by our primary care forum and our acute specialists and community trusts is a really positive step forward in thinking about how we work together.
VV: What are the top three things you’re focusing on for the next year?
GU: So for me, it is the elective recovery plan – bringing down the time people are waiting and the overall size of the waiting lists.
It is also the primary care recovery plan and creating a situation where people perceive that they have easier access to primary care.
And then thirdly, it’s ensuring that we have the strongest winter plan we’ve ever had. We want every part of the system weighing in to make sure that people get a good experience with the NHS this winter. That’s at A&E and ambulance turnaround times, and it’s about knowing there’s good primary care access and an ability for patients to access other services. It’s about admissions avoidance and early supported discharge.
VV: Do you have a plan for when a GP practice is overwhelmed? What’s the ICB’s role in supporting primary care?
GU: If an individual practice was getting into some difficulty, then our expectation would be that the PCN would provide that first level of support. The first thing you would want to do if you’re having difficulties is to look to one of your peers. It’s making those connections and helping the PCNs think about how they work together and support one another.
We have had two recent attacks on primary care premises and staff. One was in the news where a man with two very large knives cornered a healthcare assistant in a room at the Grosvenor Medical Center in Crewe.
We’re supporting the practice to ensure continuity of services and different working arrangements. And the staff needs psychological support. There’s something powerful about saying we will not tolerate any acts of violence against NHS premises or NHS staff. It’s really important that our frontline staff can get on and do their job in an uninhibited way.
VV: What form of support is the ICB giving?
GU: Through our occupational health services, we have a range of direct support to individual employees that we’ve opened up to members of that practice. It’s also just making sure that we’re in touch with the GPs and the practice, helping them put contingency plans in place regarding how they manage ongoing patient appointments.
It’s a lot of measures we learned during covid that have been reapplied. So, they’re not taking walk-ins and they’re using a closed front door policy. Even if you stand in the car park, phone, make an appointment, and then you’re let into the building.
VV: These aren’t isolated cases. Do you have an idea as to why you think this might be happening more often?
GU: It would be difficult to speculate. But I do think that the way society interacts with public services in a social media age sometimes does not show the level of respect that you would expect.
We know that people have a degree of frustration with their ability to access and gain appointments. But, if we set that in context, our hospitals are now doing about 103% of the work they were doing immediately pre-pandemic. And, just on simple appointment numbers, GPs are delivering something like 120% of the appointments they were pre-pandemic.
It has been said that it could be a number of years before we’ve fully recovered from the pandemic. We always knew that all of those missing treatments, presentations and opportunities to manage long-term conditions would have a big tail. We have to acknowledge that primary care is doing its part and doing it really well.
VV: What can you say about the workforce in primary care?
GU: The total primary care workforce in our area is 7,600 if you include ARRS. Without ARRS, it’s 6,600. And of those 6,600, over 1,700 are full-time equivalent GPs.
Nationally, there are 55 GPs per 100,000 patients. In Cheshire and Merseyside, we have over 64 GPs per 100,000 patients. And the other thing that our data shows is that more than 50% of our GPs are in the 35 to 44 years age bracket. If you compare that with the rest of England, we have a higher proportion in those younger age groups than elsewhere.
It remains a challenge for our practices to continue to work in a way that retains those people but it is, as a starting point, a reason for us to be optimistic about general practice being in a good place. We have a younger workforce to transform itself, to modernise the way it works and we don’t have a cliff edge of imminent retirements in the same way that some other parts of the country do.
VV: Is there anything you’ve put in place this winter that you didn’t have last winter?
GU: I don’t think it’s anything different, but a number of things were put in place last winter at breakneck speed and, if you put things in place quickly, they often don’t embed. There are ideas from last winter which will do better this winter because the system will know how to use them, understand them and have confidence in them.
A good example is virtual wards because last winter, they were underutilised. Virtual wards are, in almost every instance, a step down from secondary care. But we need to make sure that there’s uninterrupted and really good medical care to keep them in that virtual ward and not have them back into hospital. The learning from last winter will help us to get better utilisation this year and therefore less pressure in other parts of the system.
We’ve also got a great example of medicines management work in Sefton. If you reduce the amount of polypharmacy for a patient, you might, in turn, reduce the number of care visits that the local authority has to pay for to ensure that medicine is being safely taken. That in turn releases capacity for somebody else to be discharged more quickly from hospital. It’s finding those golden threads and then disseminating them across the whole of that patch and other parts of the NHS.
VV: How is the ICB going to tackle health inequalities as part of the system?
GU: The really important point about health inequalities is that they are about intergenerational change.
The ICB has, with its nine local authorities, adopted the Altogether Fairer programme. We identify as a Marmot community and have set ourselves 22 targets for action. All of those things will come down to how we work with young people, the good start people get in life, and the quality of jobs, education, and housing within our communities.
We have a dedicated team of people who work in this space. And we set aside dedicated ring-fenced budgets for health inequalities – a recurrent budget of £11 million annually. So, however tough the pressures on other bits of the system, we have money to spend on getting upstream and making a difference.
VV: How much do you see new technology and AI having an impact on the work that’s planned?
GU: The ICB has some transformation funds for the adoption of new technologies. We have something that we call CIPHA – combined intelligence for population health action – which enables us to use data in a way that has never been used before.
And we have used AI with our waiting lists to identify those patients who would get a better surgical outcome if they were to undertake some form of prehabilitation programme before they go into their surgery.
VV: What can you say about the ICB’s financial position after this year and going forward?
GU: People will know that we are an ICB that set a deficit plan. When you remember that the Northwest suffered covid worse than most other parts of the country and consider that the year just gone was when the government was removing covid funding from us, the financial position was very tight. And the financial position is very tight going forward.
But we continue to be able to invest in primary care. If you look at our ARRS money and some of that remaining underspend, there is still the ability and the capacity for us to bring more resources into a primary care space.
Remember, our core primary care workforce is 6,600 – the fact that we have added 1,000 ARRS staff is a significant percentage increase. And the other important thing is that the extra staff pushed a lot of practices to breaking point in terms of infrastructure – quite simply offering desks.
VV: In the wake of the Lucy Letby case, did you want to talk about regulation of managers?
GU: I think it’s a really difficult subject. I’m not sure that we should have a knee-jerk reaction. We should remember that the vast majority of people in senior positions are already subject to some form of regulation anyway.
In every organisation, there’s a medical director and a Chief Nurse or a nurse director, and they are regulated in the same way as other doctors or nurses working there. You know from my biography that I am an accountant and, while I don’t work as an accountant now, I have maintained my professional regulation. I think it’s important in terms of standards and personal values, but also because it does give another route for you to be held personally to account.