Sue Harriman, chief executive of Bath and North East Somerset, Swindon, and Wiltshire Integrated Care Board (BSW ICB), talks to Healthcare Leader editor Victoria Vaughan about creating a new care model via a consortium of partners who will provide a comprehensive and joined-up service in an outcomes-based contract.
Victoria Vaughan (VV): What are the characteristics of the Bath and North East Somerset, Swindon and Wiltshire (BSW) ICB area?
Sue Harriman (SH): We’re a medium-sized ICB with a diversity of demographics that includes urban, coastal and rural deprivation. We have three local authorities, three acute trusts and a long military history – around one in five of our population either works in the military or is part of it. The population of 940,000 is often dispersed across a large geography, with Salisbury Plain in the middle.
Our ambition is to make services work together regardless of geography. It’s about providing an offer that works for the different communities and populations, and that we’re able to reach them in a way that makes sense.
The main causes of mortality in BSW are cancer, cardiovascular disease and respiratory disease.
VV: What are your top three areas of focus for BSW ICB?
SH: One is financial sustainability. It’s important that we balance the books, use our money well, and use it as a driver for changing the way we work. We’re trying to shift the model of care and we’ve got an integrated care partnership strategy that talks about left shift, which is early intervention and prevention, and providing care and support in the community.
We are currently in procurement for integrated community-based care to help drive that. We’re looking for a consortium of partners – whether that’s primary care, the voluntary sector, the enhanced care unit or hospice care – to come together to provide comprehensive, consistent, joined-up services. It’s a novel approach in that it’s an outcomes-based contract.
Our second priority is primary care planning, making changes to generate services that are fair and equitable. We’ve started to think about those new models of care, and I hope we can get primary care to help us. There’s a real space for us to use the money differently – whether it’s service development or elective recovery – it allows us to move funds around in the right place to enable primary care to help.
And, of course, the urgent and emergency care pathway is a priority as well. We still have too many people in the wrong part of the healthcare pathway or, indeed, not getting the support that they would want before they get into an ambulance or an emergency department. So, we’re focusing on managing demand more effectively, and a really important part of that is working with all our partners.
VV: Can you explain more about integrated community-based care?
SH: Yes, it’s called the integrated community-based care contract (ICBC). In BSW, we have a very mixed market of community services provision with really mixed outcomes. I used to be a chief exec in a community mental health learning disability provider that provided primary care as well so I know that it’s a complex pathway that can be very fragmented.
The ICBC aims to bring it all together into a single space and enable these partners to work together, all as equal partners, but in service of delivering one contract around one clearly defined set of outcomes.
We hope to award a contract by September of this year with mobilisation from April 2025.
VV: When you say a consortium, how will that work?
SH: In theory, we’d have one contract, but with a group of organisations working together. If it’s successful, it would look coherent and joined up – one shared mission, one shared contract, one shared set of outcomes.
It’s a very complicated piece of procurement so it’s a negotiated process. There are a number of stages where people come together, look at the outcomes, present their response to how they would deliver them, and we work with them in the procurement negotiation phase. It’s not thousands of pages of detailed specifications. Instead, it focuses on outcomes based on a case for change around an ageing demographic, the drivers for cardiovascular disease, and so on.
The contract is for seven years plus two, which shows a commitment to this being a transformation that will take time. It won’t be that everything’s different on day one. The contract will bring together organisations that are starting to think and work differently, and we will support and enable them over the course of the contract to strive towards delivering these improved outcomes.
VV: What about workforce at BSW ICB? What’s your situation and plan, particularly in primary care?
SH: We’ve been really successful at primary care recruitment, particularly into the ARRS roles. While we feel that we’re in a good position because of that we’ve just been a bit frustrated at times that we haven’t been able to support primary care to use the ARRS roles in the way that they would want. The new primary care contract is controversial in relation to the financial elements, but there’s greater flexibility within the use of those ARRS roles, which is really helpful.
And, actually, our primary care performance data is relatively good – the access data, the number of contacts per 1,000 population and survey feedback from service users and patients are broadly positive -but because of the geography, we have a number of isolated and small practices. Everyone’s obviously part of a PCN and actively involved in that, but the challenges are slightly different depending on whether you’re in a PCN in Bath or one in the middle of Salisbury Plain.
VV: You said you wish you’d been able to offer more support to primary care in using ARRS roles; what was getting in the way?
SH: It was probably the lack of flexibility in the NHSE contract. That’s why I think it’s really good that it’s been recognised; having flexibility is welcome. And we’ll do everything we can to support primary care to be able to realise that.
With the additional responsibilities we have around optometry, dentistry, and pharmacy, it gives us great scope to think very differently about how we’re supporting primary care; not just thinking about the resource that sits in the GP surgery itself but the broader infrastructure that sits around it. So, we’ve done quite a lot of work in relation to the Pharmacy First campaign, and we have a number of community pharmacies that are recruiting independent prescribers.
These are all things that can help to balance that workload in primary care.
VV: What about primary care access? Northwest London set up a same-day access hub and, at PCN level, the Foundry Practice in Lewes set up urgent on-the-day access hubs. So, what are your views in terms of access hubs and splitting off continuity?
SH: I’m always open-minded to what would work but for something like this, I think it’s better to do it in partnership with those closest to the services. All of our PCNs have submitted a plan in relation to that, and we will go through that information and work with them to understand what might be best for us.
We do have some examples. Last year, we opened Devizes Health Centre in Wiltshire, which offers a shared same-day service. It’s going down really well and has been effective.
It works because it’s great real estate, digitally enabled and connected, and it was driven by clinical leadership in primary care, which makes all the difference. All those things need to be true for these things to work, and that obviously costs money and takes time and planning. But we would want to move towards more of those offers with the right factors in place.
When it comes to primary care access for BSW, we’ve seen a really significant level in access to primary care – a 13% increase in GP appointments since 19/20, with 65% of them face-to-face and the rest on the telephone.
VV: Given primary care is so disparate in the BSW ICB area, how do you engage with it?
SH: All our practices are represented by a PCN. We have monthly meetings with the GP reps from each of the localities where we look at current issues or co-design plans. And we go to shared events together. For example, there was a primary care leaders’ event led by Claire Fuller and we went there with general practice. So, we’re learning together.
We also work actively and closely with the LMC and try to have a really open and honest dialogue. My sense is that they prefer that – they feel that there’s no hidden agenda. We try to work in a high-trust space.
We’re also thinking beyond medical engagement, so that’s engagement with the multidisciplinary team sitting in and around primary care.
VV: What about integrated neighbourhood teams? Do they exist at BSW ICB and if so, what do they look like?
SH: Our first integrated neighbourhood team launched in Swindon in April. We’ve used the local health inequalities data to help us identify the cohorts of people and services that we need to think about coming together. We’ve got some of our most deprived populations in Swindon so that’s the focus there.
I guess everyone may be coming at it slightly differently, but our teams are primary care, community health care, mental health, community navigators, and some of our local Live Well hubs too.
So, we’re just stepping into that, and we hope it will motor quite quickly.
VV: How are you approaching your financial position at BSW ICB?
SH: We’re looking at all the basic housekeeping to make sure productivity and efficiency are improved and thinking about how services work together more effectively. For example, our acute sector – the three hospitals – are working together differently at scale to be more productive and efficient. It’s thinking about where there’s an opportunity to do things together or do things once.
We are also in the process of rolling out an electronic patient record system over the next couple of years. We’re a very digitally poor ICB, particularly in Wiltshire, so that will be a significant enabler for us to work differently. We’ve got really good uptake of the NHS app and it’s being sure that we can equip people to self-serve and navigate that.
Capital is obviously very tight, so we have to think about capital prioritisation and making sure the money goes into the most important things.
We also need to focus on workforce. We’ve been successful with our recruitment across the board, but it maybe hasn’t kept in line with the shape of services that we would want for the future.
And, of course, we hope that creating a coherent out-of-hospital system – which we hope the acute system will be part of – can engender a left shift of resources and money across that pathway. That would ultimately mean that more of the BSW pound is spent on early intervention and prevention. We’ve got some really good business intelligence that we’re using around our case for change, and we hope that will result in a systemic and material shift in where our services are and where our money goes.
VV: How does BSW ICB plan to change the way things are funded to tackle health inequalities?
SU: We’re trying different approaches.
We’ve used some of our money to seed fund 35 smaller projects across the integrated care system. We asked the three integrated care alliances to respond to the question: if you had some money, what could you do and how would that improve outcomes, particularly thinking about prevention and early intervention?
Moving forward, the BSW priority is on prevention and health inequalities around hypertension and those likely to experience cardiovascular disease. So, we’re looking at how we focus on the Core20PLUS5 groups and we’ll use that as proof of concept around targeting key groups of people with interventions that improve their outcomes and reduce their dependency on healthcare.
VV: Finally, where do you hope to be this time next year?
SH: This time next year, we’ll be launching and mobilising the ICBC with multiple partners working together very differently in an integrated community out-of-hospital infrastructure.
I hope we’ll be financially stronger – we’re striving to deliver a breakeven position in 24/25 – and that we’ll have embraced the new flexibilities that result from the GP contract change.
Finally, ICBs are only two years in, and we’ve been through so much change, working towards the 30% running cost reduction. So I hope to have people around me who know they’ve got a secure future and we’re working in a new smaller team with our partners in a collegiate way.
