Shane Devlin, chief executive of Bristol, North Somerset and South Gloucestershire (BNSSG) ICB, tells Healthcare Leader’s editor Victoria Vaughan about how plans to allocate funding to address deprivation and health inequalities require a different approach – and some difficult conversations.
Victoria Vaughan: Could you give an overview of your ICB?
Shane Devlin: It is a remarkably diverse population and very well-hidden diversity. People think of the South West as this lovely fluffy middle-class ‘isn’t the world wonderful’ kind of place. While there are some parts like that, it can feel quite different, literally street by street. Alongside some very affluent places, we have areas that are in the bottom 10 per cent of deprived communities in England.
We have an ageing population growing much quicker than many other ICBs in England. And we have a large and increasing number of 15 to 24-year-olds. So we’ve got this diverse challenge at both ends of our system.
For me, what’s amazing is that we have some huge providers in North Bristol Trust and University Hospitals Bristol and Weston NHS Foundation Trust. It’s unique to have two large trusts within walking distance in a medium-sized city like Bristol.
We have a strong primary care federation. All of our GPs are members of One Care, and it’s a bit of a gift as many other ICBs don’t have this unique and single voice of primary care.
Of course, we all know primary care can’t and doesn’t speak with a single voice in everything. It’s never going to work that way. But it’s unique that we don’t have to go to 27 people and instead have that person at the board table who represents GPs.
We’ve just completed a full new needs assessment, a joint needs assessment and a massive engagement process with the population to help our understanding. It reflected a lot of what we knew but also highlighted that we have some pretty diverse health outcomes, and we’ve got to try and get behind that.
VV: In any particular areas?
SD: There are 10 healthy years of difference between the people who live in our most deprived area and our least deprived area. So, a person aged 55 in our most deprived area has the same health life as someone of 65 in our least deprived area. And literally, that could be a bus ride away, which is just really eye-watering. We’re using the Cambridge Score against certain populations, which shows this extraordinary difference.
That becomes a fundamental role for the ICB. How do we tackle that and level up while avoiding levelling down, which is a concern?
VV: In terms of your ICB, what are the top three things that you’re focussing on at the moment?
SD: Well, we’re trying to look at four things.
The first major area is improving the lives of children because we haven’t focussed on that as much as we should have. If you look at the issues of adverse childhood experiences, in terms of child obesity, which is grown considerably over the pandemic period, and you look at some of the special education needs work, we have a major piece of work in terms of improving the lives of our children. So, that’s the first big area.
The second big area for us is improving the lives of people with mental illness and learning disabilities. We’re doing a lot around this – very simple things like access to primary care and physical health checks. We’ve got a local community model.
The third big area is what’s called Improving the Lives of People in our Communities. And that’s where we’re trying to drive our integrated model; we have an integrated model of six localities involving primary care, the community, and local authority.
And then the fourth big area is improving the efficiency and effectiveness of our hospital system because as much as we know the answer to our problems lies in the community, we also know that we have two massive assets, our trusts. So we’re looking at how to drive improvements there.
VV: What’s primary care’s role in those four aims?
SD: It’s massive.
We think about it in terms of our six localities. They’ve been up and running in pilot form for about 18 to 24 months. They’re really coming into their own now. We focussed heavily on testing whether we could create a local community-based mental health and wellbeing service through them, to begin with. So it was building the team around the general practitioner, around the population, and that’s working really well.
We’re now looking at the big aims for each of those six for the next three years. Some of those want to look at childhood obesity as a main driver, some of them want to look at frailty, and some of them want to look at social isolation. It’s whatever is right for the local population.
Primary care sits in the middle of those locality partnerships, alongside the voluntary and community sector, the community statutory sector, and the communities themselves. And we envisage that’s how we’re going to devolve our resources.
VV: How do you apportion this devolved resource?
SD: In the pilot year, they decided what they needed to do, and we, with no recurrent money, made it happen. We’re coming to the end of that in March, and we’re now having that conversation about, ‘Well, what is the best way to allocate money through those patches?’ I have this view that we’ve got local population needs analysis, and therefore, the resource should clearly and directly match the local population needs analysis. That’s the view I would like at the moment. It’s a little bit more complicated than that because that may mean there are winners and losers.
VV: So rather than funding based on population numbers as it’s usually done, you’ll look at population deprivation?
VV: What are the barriers to this way of distributing funding?
SD: The barrier is that, in some cases, that could mean that there will be certain communities which, if you do it through a true needs base assessment, may not need all the money they’ve got at the moment. And that destabilises it. So, the way that we’re looking at it is the new money approach.
We will have new money to invest in our localities. We have managed our money well, we are going to break even this year, and we’re planning a medium-term financial plan, which allows us to identify amounts of new money for the communities. And we will allocate those based on the community needs assessments.
Rather than going back and pulling apart some of the stuff that already exists, which can mean you accidentally level down rather than level up, we will begin to take differential investment decisions with the new money. We’re not necessarily trying to drive equity of access – we’re trying to drive equity of outcomes.
If you believe in the equity of outcome, you’re not looking and saying, ‘Everyone should have the same thing.’ You’re actually saying, ‘Everyone needs a different thing if we’re going to get to equity of outcome.’ And that’s fundamentally at the heart of what we’re trying to do.
But that is shifting a system. If you think about the way we’ve done it before, it’s been based if you’ve got 100 people, you get this amount of money. We’re now saying, ‘Actually, if you’ve got real, you know, hard-wired inequalities, and you’ve got real deprivation, you have to have more of the new money than somebody who doesn’t’.
VV: It’s the difference between equal and equality, isn’t it?
SD: Yes, it is. And it takes it even further than that. It takes it to the point of justice, which is that we are public servants here to serve the public. The point of justice is that people get what they need to flourish. And that’s the kind of approach we’ve got to take.
It’s going to be really hard for some people because if you currently have a population that is well-served, it may feel like you’re not getting your fair share. But if you believe in the equity of outcome rather than the equity of access, which I think we should, then you have to start changing some of those dynamics.
VV: Who are the people that you’re having to convince? Is it local authorities, is it GP practices or federation groups?
SD: That’s the point. Will they be losers because they won’t lose anything?
VV: No, not if everyone is in better health and all communities thriving, but do you need to make that case, though?
SD: You have to make that case because people assume it will mean we’ll take money away to give to somewhere else. And that’s not the approach that we’re taking. We’re saying, ‘We’re not going to invest further here with you because others need more to get to a different place.’
Don’t get me wrong; this is not an easy argument because some people will say, ‘Well, what about my share?’ But if you believe in the outcomes and the evidence shows that some of our communities are not getting the outcomes they deserve, it’s a really strong argument.
Going back to the start of our conversation, you can say, ‘Well, your population is living 10, 12, 14 years longer than somebody five miles down the road. Now, please argue with me that I should not give the money to them as opposed to you’ because if you go to the evidence, that’s where it will take you.
It’s interesting, I met with a large gathering of GP practices and they are worried because irrespective of whether your population has high outcomes or is struggling, it doesn’t take away from how hard you are working as an individual practice.
I’m not pretending this is in any way an easy thing to do, but if we’re going to live by our outcomes, we can’t carry on doing what we’re doing. So if you’re really going to drive improving population health, reducing inequality, value for money and socioeconomic development, then you do have to change the system.
VV: So this new funding will go through the localities/places, and then they will decide what various projects they’ll fund to tackle these issues?
SD: During the pilot phase, that was the starting place. Let communities decide – take the numbers, and they’ll make the right decision.
Then you quickly realise that certain things need to be consistent across all six. For example, schizophrenia – I doubt that population A will want a different pathway to population B. So, there are certain things where you need that standard offering.
We’re trying to get the balance right between how much is totally decided by the locality and how much is decided by the central system.
VV: You’ve mentioned your two big hospitals – North Bristol Trust and University Hospitals Bristol and Weston NHS Foundation Trust – and a major concern of this move to ICBs is that the voice of primary care is lost. You also mention your strong GP representation through One Care, but in terms of managing your acute trusts in this system, how much do you feel you’re hearing from them versus primary care?
SD: First of all, our board is a little bit different from other boards. We’ve brought every provider onto our board, so everyone’s voice is heard.
And we created something called the Executive Group, which allows the chief executive of One Care to have an equal seat at the table to the chief executive of North Bristol Trust. We’ve done a lot of development work with all the chief executives, and we’re taking a team-based approach.
VV: It’s quite a cultural shift to work in teams like this, isn’t it? And if it works – and more people are kept out of hospital – the hospitals perhaps won’t do as well?
SD: Our hospitals are now being measured not on how many x, y and z they do, but on how long someone stays in hospital. It’s being measured on the appropriateness of what they do, measured on discharge. Our hospitals know that, for them to work well, our community and primary care providers must also work well. So there is no incentive for our hospitals to avoid working with primary care, and we’ve got to that point where we really, really understand that.
We’re developing quite a unique way of looking at information called Care Traffic Control. The concept is that we will have one single dashboard of the whole system. It will allow everyone in the system to see what’s happening elsewhere at any moment in time. And that’s whether you’re a primary care practice in Weston, the Emergency Department in North Bristol Trust, or a care home wherever. It will allow anyone in the system to see where the hotspots are and how things are flowing.
That allows you two things. One is to take systems management decisions which is what we do. But, more importantly, it’s to take predictive analysis to another level. It will allow us to understand where the hotspots are and then try and do something with that information.
We’ve gone through the pilot phase, the beta phase, and we’re now out with a strategic partner. We hope to have a usable, out-of-testing model by June.
VV: Is it part of the system control centre?
SD: We started on this path before the system control centre. I came from Northern Ireland where there is an integrated health and social care system, and we had this approach. You’ve got to have data that gives you a single view of the truth. So, we were starting anyway, and then the concept of single control centres came along.
VV: How are things going in terms of your workforce? What can the ICB do to support the workforce?
SD: Workforce is undoubtedly the single biggest challenge. We have an interesting dynamic, which is that we have quite a high level of turnover in the BNSSG. We are doing work to try and understand that. It is not necessarily people leaving BNSSG but moving jobs within it. This basically means we are not getting a huge import of new people into the system. As a result of that, we have quite a crippling agency spend. In one of our providers, for example, over 20% of their workforce is agency.
If you are a Band 5 nurse or working as a trainee doctor, the cost of living in the South West is remarkably high. Housing to rent is hugely expensive, and you need to win the lottery to buy a house if you have not started at 20-something. That is a big issue for us. We’re exploring what we can do to support our workforce in terms of housing options.
So we’re doing lots of thinking on our workforce strategy, and we have just appointed a Chief People Officer to the system.
We are looking at creating a single learning academy so we can start to develop learning across our BNSSG system. And we are looking at recruitment, as many are.
There is no doubt that GPs will be a major focus of our strategy. We do not have a massive amount of GPs exiting at the moment, but the medium to long-term challenge is undoubtedly about how we create a better work space for our GPs. If they fall over, the system falls over.
VV: How can your support the GP workforce?
SD: We’ve just been through a capital evaluation process, asking all the parts of our system to put forward what they believe they need in terms of capital and estates. There is no doubt that there are some parts of our primary care system which do need investment. We do not have a huge capital budget, but we do have capital.
We’ve asked all PCNs what they think is needed to modernise. There is a process going on at the moment where we have taken all of the bids – of which there were many hundreds, I may add – and taken a common sense approach for a two-year capital view. We will build a 10-year capital view, but to begin with, we need a two-year view looking at what we will do differently.
The other thing we have to look at is whether the systems are working – the likes of how people get access to the GP. Is it through AskmyGP, or is it through better telephony? There is variation in that. So, if you go to Practice A, they have a system which actually makes that process easier, whereas we have other practices that do not have that level of business function. So there is work that we need to do on that.
VV: Do you see the ICB as supporting that?
SD: We have our six Locality Partnerships and they are, in many cases, made up of two or three PCNs. So we are looking at The Fuller Stocktake, and we have done an assessment against it. We are looking to see what actions we need to take this year because there is no doubt our GPs are seeing more people than ever. So I see The Fuller Stocktake as being a key part of starting to look at how we do this differently and what are the different roles needed in the GP practice.
VV: Do you think Fuller and the Hewitt Review will sit well together?
SD: I do. I have been involved in some of The Hewitt Review work – I was part of some of the early discussions with Patricia Hewitt – and, absolutely, they will fit very neatly together.
We’ve got to try and get an accountability model that is right. We have got to get digital that is right across the system. We have to understand how we take on the workforce challenges. We must understand the right performance-related regime, so it is applicable to primary, secondary, tertiary or community. So I do not see them clashing at all; quite the opposite – they are actually very complementary.
The challenge will be the change capacity to get on with it. Once we look at the recommendations, whether in Fuller or Hewitt or wherever it may be, it will take us to have dedicated change capacity to make the change. We cannot simply tell a PCN to get on with it. It is the job of the ICB to create that change capacity to support the parts of the system to move forward.
VV: There has not been a lot of support for PCNs.
SD: I think you are right. As the ICB, we have to work really strongly with PCNs. For us, One Care is great and we can work with them. They have got good architecture as an organisation.
VV: Do the PCNs and One Care speak with one voice?
SD: Yes, absolutely. The PCNs are strongly embedded into One Care. We’ve got such a strong connection with GPs through One Care.
And then we bring in other elements such as dentistry, pharmacy and ophthalmology, and we need to build that same strong connection. We’re in the early bases of understanding how we do that and whether we follow a kind of One Care model. A lot of work has gone on with One Care to bring it into the family, and we have got to do a similar thing with pharmacy, ophthalmology, and dentistry. It is a great opportunity – we’ve just got to get the model and the system right.
VV: You are talking to those groups already?
SD: Yes, lots of engagement. We have the Primary Care Committee of the ICB, and those groups have been involved with that since we began. Obviously, we do not commission their services yet, but we will come July.
VV: How do you feel about the financing of ICBs in general, and what would be helpful? Because at a lower level, PCN leaders are concerned about different funding pots that come in late in the day. What it’s like at a system level?
SD: A finance director described it to me as purses. You’ve got all these little purses, and you’ve got a few pounds in that purse and a few pounds in that purse. But that will change this year.
The planning guidance was released on 23 December, and then the financial guidance came alongside it, so there’s been a lot of tidying up with those little pots. So, it’s going to feel different because the money will come to ICBs in much bigger pieces, allowing ICBs to share the money differently. So, it’s feeling better in that sense.
You are correct about the short-termism of the last three months. It’s fair to say lots of money, which by the way, has been both welcomed and well used, is coming in big chunks. I don’t think you will see that next year. You’ll see a much more recurrent nature of funding because the planning guidance is driving a much more recurrent approach.
Now, it doesn’t mean we’re getting lots more money. It just means that we’ll know what we’ve got rather than wonder, which is really important.
What’s important for us is that we can say we’re going to break even this year. We still have an underlying deficit – that’s the point of the system – but we have a financial plan to get us out of the underlying deficit, and we’re on track for that, which is really good.
VV: In a year, where do you hope to be, what would you like to have achieved and what would success look like for you?
SD: For the system, I would like to see our six localities up and running and delivering benefits. So, I would want to see the localities really come to life.
I would like to see that our board works – that the partnership is palpable.
And then the final area is flow. That is really killing us as a system. It’s too high in Bristol North Somerset South Gloucester. In fact, the southwest is too high, and we’re too high within the southwest. I don’t just mean hospital; I mean system flow all the way from primary care, secondary care, and discharge into the community.
Therefore, success for me would be getting some of that down so we can enable different and new models. It’s not about looking at discharge from a hospital perspective, but it’s actually looking at how we keep people well. We’ve called this Home First, and it’s our overarching process.
The best bed you can be in is your own bed. That’s the motto we have to follow. And therefore, we have a range of actions in Home First, which will be admission avoidance in primary care. It will be intermediate care, both step-up and step-down. It will be a domiciliary care market that can look at discharge but, more importantly, look at people in the community before they get into hospital.
That’s actually what we’re about. Does our population remain at home for as long as is physically possible? So, what success looks like for me is Home First working well.
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