NHS Lancashire and South Cumbria is a large health system in the North West of England, covering 1.8 million people across a varied geography. Chief executive Kevin Lavery gives an overview of the ICB in an interview with Healthcare Leader’s editor Victoria Vaughan
Victoria Vaughan: Can you give an overview of your ICB?
Kevin Lavery: Lancashire and South Cumbria is a pretty big ICS with a population of just under two million and pretty varied geography from industrial Lancashire up to the Lake District area – the sparsest rural area in England. We’ve got the coastal towns with some unique challenges and opportunities as well so there’s really varied geography.
We probably need something like an ICB more than most areas. In terms of joining up the system and dealing with the inequalities we face. They’re pretty stark. Places like Blackpool and Blackburn really do have some pretty major challenges and it does require a system approach, more emphasis on the front end of the system, primary care and the wider community services. More emphasis on prevention programmes, we really need that more than most areas.
VV: Has the disjoint that’s been happening to date exacerbated those health inequalities?
KL: I don’t think you can argue with the fact that they’ve worsened in recent years particularly during the pandemic and we’re going to have massive challenges with the cost-of-living crisis as well, so we have a major task on our hands here and it’s not something that can be turned around in a few months this is going to be years and decades. It does need a really focused agenda to address it. Probably the starkest figure of all is the healthy age span for men in Blackpool is in the mid 50’s. It’s about 10 or 12 years shorter than the best in England which is quite stark. So we do have some really big challenges, but they’re not easy to solve. It requires action over a sustained period and obviously we can only do part of it in the health service which is why it’s really important that we join up with other local agencies, in particular, local government, the voluntaries sector and, the police service etc. They can all have an impact too if we move in the same direction.
VV: Are you getting a sense that you are bringing everyone with you at this point?
KL: I think it’s early days. We’ve had some chats, it’s a big change in the system. If you think about it the health trusts have been encouraged to do their own thing for a very, very long time. Now, one of the attractions of coming to Lancashire is, we’ve got a relatively small number of trusts for a big area so you can get everyone into one room and the relationships are good so there is a good collaborative culture already which is a good foundation to build on.
But it does mean quite a big cultural change in the system and it’s a big cultural change for primary care too. This is a very different world to the set-up of the CCGs which were sort of GP led. There’s some significant changes here and that will take time.
V: CCGs had a 10 year shot, many I’ve spoken to didn’t think it was long enough. You’re talking about a long-term commitment to the system, do you get the feeling that your ICB is really going to be able to pick up the baton from those CCGs and that you will get that long-term support?
Kevin: As a public sector leader you’re a custodian of the system and the taxpayers money and you’ve not just got to enjoy being in the seat of power, you’ve got to use it and do the right thing. The ICB’s key strategic aim is to improve outcomes in health, tackle the inequalities, enhance productivity and value for money and it’s to help with that broader community development both economic and social. The way I would approach it is we’ve got to get our capital and start doing real things in all of those four areas that make a difference. A real difference. If you take the inequalities, we were one of the ICB’s that brought in Michael Marmot. We’ve got a session with the leaders across the system in the middle of October launching that report. We’ve got to do something serious to respond to that.
We’ve got some real stresses and strains in our primary care system and we need to see some real change and that will require investment too. And we know that we’ve got some major challenges in our hospital system. We’ve got around 500 people in our hospital system who don’t need health care.
We’ve got huge spend on agency staff, we’ve got expensive support services because everyone’s doing their own [thing]. It we can do something about these challenges we can make a real difference to productivity in our system. If we can grip the national challenges on the financial side, then we can use that money to fund some of the things that are needed in the community and in the hospital system to do more for the same.
VV: What are the top three priority areas for the ICB?
KL: The first is to strengthening the community side of our system by investing in prevention programmes, and the integration of care and health and primary care plays a vital role in those areas.
The second area is to help our hospital system be the best it can be. We have four hospital trusts in Lancashire and South Cumbria and we’re underperforming as a system. We know that’s not great for quality of service, it’s not great for efficiency either so we need to see rapid change in that area. There are lots of opportunities to improve efficiency and effectiveness and if we can correct that we can then help fund some of the improvements in quality for our hospital system but also those community developments I mentioned earlier.
The third thing would be around changing the way we do things so there is collaboration and system thinking. For example, we spend a lot of money on agency staffing as a system, it’s £270 million a year, that’s a big number, that’s not just a financial issue it’s a quality and safety issue. If you’ve got lots of churn and changing staff it increases the risk doesn’t it around patient safety? It’s critical, it’s not just about how we manage agency and temporary staffing it’s about why the system has issues? If we don’t have those 500 people who don’t need to be in the hospital, we don’t need as many nurses and doctors.
VV: What are your expectations from primary care this winter?
KL: Things like the Virtual Ward programme will make a big difference and primary care has got a role to play as people are effectively going to be out in the community rather than in the hospital. That’s a bit of a game changer in terms of this winter and next winter. Effectively it’s not far short of a 20% increase in bed capacity so that’s pretty significant. Another area to look at is the arrangements with social care and primary care around frail elderly people who don’t need to be in the hospital and should really be in the community with that wider support around them. We are looking at some programmes which are still under negotiation to increase our intermediate bed capacity in the area and we’re also looking at some investments in the of domiciliary care space and again they’ll only work well if we’ve got full alignment with the local authorities and with our primary care sector.
VV: How is that alignment going? There was criticism from local authorities that Sustainability Transformation Plans (STPs) were set up in isolation. How are you approaching bringing different sectors together?
KL: You’ve got to be accessible and get around. I’ve had lots of meetings with our primary care sector, some of them have been challenging because there is a sense of loss with the CCGs and we made some changes to our place based boundaries. It’s not a black and white thing, you don’t want to stop something that’s working, that might go beyond the administrative places that we have. For example, we have a discharge team in Blackpool Hospital that has got three groups of staff working as a joint team from social work in Lancashire County and Blackpool Council and the hospital. It operates across two places and that’s fine. But there were concerns among primary care leaders that it could undermine some of the relationships in certain areas such as Morecambe Bay. What we’ll do with that place is we’ll work that through with them, and if things are working well across two places, why would you change that? So we have had some tensions.
Local government in Lancashire and South Cumbria is going through some change, so we’ve got a new unitary council coming in for Westmorland and Furness which is not entirely aligned with South Cumbria sothat will create some new problems. Currently under the arrangement, Lancashire was in all five place based partnerships. Well, you’re not going to get any integration. It’s just too hard. So we’ve been going through the process of changing the boundaries of our place-based arrangements. That has been a concern for primary care.
So there’s issues of making sure that the new arrangements don’t damage any good working arrangements that they have, particularly with the hospital. We make a commitment to that. But also there’s sort of a sense of loss with the move away from CCGs, and the role they.
But it wasn’t all about primary care. A lot of it is about social care as well. I guess the challenge there for us in Lancashire and South Cumbria is to embrace and engage with local government which we’ve done. We’ve got four people now appointed to the place-based roles we’ve got two from health and two from local government. So I think it’s a good mixture going forward. But there’s a lot to do. I think it’s exciting. Yes there are going to be challenges when moving to this bigger territory with system thinking and collaboration. And my commitment would be to work through those and be accessible as a leader, and be upfront about the key changes. And not shy away from it.
VV: Are you working on a primary care strategy at the moment to address challenges in these areas?
KL: Yes, we are. At our second business meeting we had a deep dive on primary care. It’s going to be one of our critical issues. I’m no expert on this. We’ve got a senior GP who sits on our board, Dr Geoff Jolliffe. We’ve got some senior primary care leaders in our team in the ICB. I’m looking to my primary care leaders to help us through that journey with the wider sector.
VV: Are you doing anything to make sure you maintain those CCG clinical leaders who are disenfranchised?
KL: They’re probably feeling a little uncertain at the moment because we’ve put some temporary arrangements in place, and we’ve got our medical and nursing director working through that with the clinicians across the sector now. So yes, there will be changes. There need to be changes. But it’s critical for us that we have a strong leader. And it’s critical for me as a non-health person coming into Lancashire and South Cumbria ICB – I need that support.
VV: What is the advantage of you not being from that NHS background?
KL: I’ve spent a lot of time in local government. I’ve worked around the health system on adult care and child protection. But I’ve also worked in the commercial sector providing sharde services to organisations, being involved in staffing, employment companies that supply staff, etc. And I’ve been involved in the tech sector I ran a start-up business that today employs 2,000 people. When you go back to, what’s the ICB about nationally, it’s about improving outcomes, tackling inequalities, improving productivity, and helping with that broader community development. Actually I can tick quite a few of the boxes.
I’m not an NHS lifer but I’m not a novice either. Having worked on adult care and child protection and things like that, I’ve worked very closely with health leaders in places like Newcastle-upon-Tyne and in Cornwall, and there’s some great people. I can bring something to the table in terms of the broader economic development and the opportunities we have there. How we take advantage of some of the efficiencies, opportunities in our system, you know, around shared services and employment of agency staff. But also how we do that integration across the broader community. You’ve got to remember that actually the health service has relatively little influence over the determinants of health, but local government has a huge influence. So I think those connections are helpful. But that also means I’ve got to be humble and recognise that I don’t have the healthcare expertise, so I need a really seasoned team of healthcare experts that do, and work with them and that’s what we’ve assembled.
VV: What’s your perception of primary care in your area?
KL: I think it’s performing better than the national average, for sure. And the data supports that. So a lot of people are getting same-day appointments. It’s interesting though that a lot of people are not seeing GPs, they’re seeing nurses and so on, and that’s good, we need to do more of that. But yes, it does need attention, for sure. We do though need to make sure that the right people are seeing the GPs, and we’re not clogging the system up, if we’re going to be effective. Primary care is a broad family, the GPs are a critical part of it, but so are the pharmacists, the nurses, and we’ll have these new responsibilities going forward for dentistry and optometry, etc. So looking at the broad church is going to be critical too.
VV: Do you have an idea of how you’re going to look at this issue around workforce in your area?
KL: Like every other ICB, we’ve set up a people board. We’re going to have a workforce strategy, and it will delve in and figure out what the critical priorities are in this. And we do have an ageing workforce, so we’ve got a lot of people approaching retirement. Recruitment is much harder in areas like primary care, and in particular parts of our geography too. We have very good retention, though. People, once they’re in Lancashire and South Cumbria, tend to stay, which is a great plus. I think there are a bunch of things that we need to do, but again I’d be looking to people specialists across the system for advice.
There are a bunch of obvious things. We need long-term partnerships with the various health education organisations in our area, and just outside our area, who we rely on heavily. So we need those strategic partnerships. We’ve got some universities who also do target, if you like, hard-to-reach communities to get new people into health education. So I think that’s a critical area. It’s not just about staffing and recruitment and retention, it’s about those wider system things. If we’re able to manage down the bed-blocking challenges, we’re reducing the demand for nurses and doctors.
The other area around primary care is to develop that broad church, to get more people seeing the pharmacists and the nurse, to reduce the pressure on the general practitioners. There are some systems things that really do address those workforce issues, and probably in the medium term, and I’m not an expert on those so I would be looking to our clinicians for advice, is multi-skilling and multitasking.
VV: That population health management approach requires a long-term investment. Can the ICB support this long-term agenda?
KL: It’s generational and it’s the same on the inequalities agenda it’s decades and generations. I think the fears are well-placed. As an ICB leader, I want us to make a serious dent on those long-term problems. And I realise the returns are very long-term. They’re beyond 10 years. I think the trick here though is to have some early wins in the prevention areas. It might be smoking cessation for example, for women who are pregnant. It’s trying to identify those areas where you can show progress, that give you the mandate to simultaneously invest for the long-term. When you look at the population health agenda, it’s critical that we can create some short, medium-term successes that we can celebrate while at the same time doing the right thing for the long-term. And that’s one of the things that we already commit to as part of our strategy. We need to create the money to invest in that population health agenda. We’re already investing significant money around the creation of the population health team, the supporting of the Michael Marmot work. It’s a critical area for us. But you’re right, these are beyond any political horizons, aren’t they? But they’re really important for the long-term health of Lancashire and South Cumbria, so we’ve got to address them. We can’t ignore them.
VV: What’s the ICB’s financial position?
KL: Like most ICBs is pretty challenged. We’ve got basically a standstill budget with a sharp increase in demand and some real stresses and strains from the pandemic and with cost of living. That’s the scenario. So yes, it’s tough. And it’s probably going to be challenging for a few years, isn’t it? That’s why I think, one of our critical roles in the ICB is to look at increasing productivity. We’ve got to use that as a burning platform to do that fast. So that we can create as much flexibility financially within our organisation to start investing in all of the things that we’ve talked about, whether it’s the broader church in primary care, the prevention programme, critical areas of social care around domiciliary care and intermediate beds, and there’s quite a lot. I mean, I’m a half-full person. Even with that standstill environment, if you do the systems thinking, and you grasp the various nettles that are there, we can do quite a lot.
VV: Where would you hope to be this time next year?
KL: There are beginnings of some transformation areas. But there’s some probably housekeeping required – a more stable organisation which is signed off, a long-term plan with a longer-term budget which I think is critical for some of these big changes. Because to have an annual budget system is crazy. So we’re going to have a 10-year plan with a three-year budget. To begin that process, to have the integrated care partnership strategy all signed off. But I think in terms of real transformation, it’s starting to see some real difference in some of the areas we’ve talked about. So some more intermediate bed provision, some investment in domiciliary care, that’s making a difference. I think there are also a whole bunch of pressures that we read about pretty much every day about urgent and emergency, we’re going to have a really tough winter, so we want to give a good account of ourselves in a very challenged situation and get a system to perform as best we can in that constrained environment to make a difference. And that we can look back and say, actually, we did well, and we’ve got more capacity in terms of virtual wards and we’ve got those investments in domiciliary care that will make a big difference when the winter in 12 months’ time approaches. They’re the sorts of things. Financial stability, service stability, keeping a good account of ourselves when we’re really under pressure, but then beginning at the foothills of the real transformation change around primary care, around the investment in prevention, around the connections with social care. It’s all about what things are going to be different for patients and for citizens at the end of the day.