Dr Chris Clayton, chief executive of Derby and Derbyshire ICB, talks to Healthcare Leader editor Victoria Vaughan about developing a new model of general practice and how integrated care is key to balancing the books.
Victoria Vaughan (VV): What are the unique characteristics of Derby and Derbyshire ICB?
Dr Chris Clayton (CC): I’d say a unique characteristic is the clarity and coherence we’ve got within the NHS space and the broader partnership. We’re very clear about the problem we’re trying to solve, which is improving healthy life expectancy and overall population health, and the approach we’re going to take collectively to do that.
Between us, we’ve worked out the NHS’s role and what we need to do in partnership. The Integrated Care Partnership (ICP) – the partnership between the NHS, local authorities and the voluntary sector – is focused on health, public health and social care. And our two health and wellbeing boards are focused on the wider determinants of health – housing, the environment, and so on.
VV: What are the top three priorities for your system right now?
CC: In the NHS space, mission-critical is stabilising the urgent emergency care system.
Obviously, that’s linked to the flow into and out of our hospitals, and so we’re thinking about how we can improve our waiting list position.
And the third priority is keeping an eye on tomorrow – so what preventive schemes could we move with? One of the things we’re focusing on is cardiovascular disease and we’re hoping to do a key programme around reducing the incidence of high blood pressure.
So, that’s the NHS space. In the partnership space, we’re finalising our priorities.
We’ve agreed that we want to do some work around school readiness and we’re hoping to go further with local authorities on smoking reduction in line with national policy.
And in the ‘age well, die well’ part of the ICP strategy, we want to do something around the community model of care outside hospital, linked to the capacity and integration between services needed.
VV: I know you’re looking at a new model for primary care – could you speak about that?
CC: In general practice, a key priority is the model and future sustainability. We’ve got an emergence of thought across Derbyshire, and that’s why we haven’t fully come off the fence yet—we’re working through the benefits. We’re a broad community, so there’s no one model that will solve all.
I’m a big believer in the partnership model, and it has huge benefits, but it won’t succeed without support and strategic policy support.
We’ve got some really interesting examples emerging, such as the Erewash model where they’ve created a super partnership. So that’s one to watch. We’re obviously supporting and keeping a strategic eye on the benefits that come out of that, but it wouldn’t work in every part of the patch.
VV: How is Derbyshire in terms of GP numbers?
CC: Historically, Derbyshire has had a reasonable GP workforce position, but that’s changing. And it’s different across the county and city.
We’ve got a mixed economy of models of general practice. In the Peak District and the Dales, we’ve still got quite a traditional partnership-based model whereas in other parts of the county and city, we’ve got other models emerging.
The challenge is converting trainees into longstanding GPs who go into partnerships or stay in the local economy. We’ve also got a challenge around retirement and people retiring early. It isn’t just retiring—it’s people choosing to leave partnerships to do other things, and that’s a worry for us.
VV: What’s your ICB doing when it comes to implementing Fuller? In northwest London, they’ve come up with the idea of creating a same-day hub which has attracted a lot of attention. Is that something Derby and Derbyshire ICB is looking at?
CC: From my past experience – I was a GP and a CCG chief exec – I think we need to be careful about completely splitting off urgent on-the-day care versus continuity of care versus complex care.
We’ve got versions of this going on – examples of on-the-day care systems where, at PCN level, you’ve got pooling of resources and managing urgent care.
But I think it would be a mistake to fully disintegrate those two things because connectivity is important. What safeguards would you put in place to spot people who were frequently using that service and not getting continuity of care? You need systems and processes to spot people who might have underlying issues.
As a senior colleague once told me, a lot of urgent emergency care is long-term conditions that are exacerbated.
VV: There’s a link there with health inequalities, isn’t there?
CC: Yes. We often think that urgent and emergency care is in A&E, but a huge amount is happening in everyday general practice. It isn’t one or the other. Both are happening all the time.
Strategically, we’ve got to join the dots and look at what’s driving it – link it to health inequalities, long-term conditions and what’s going on underneath in the population health.
VV: The new contract changes the way money goes from the ICB to PCNs – it’ll be delivered when they can prove they’ve achieved modern general practice. How will Derby and Derbyshire ICB manage the relationship with primary care?
CC: I’m not worried about it. I’m worried about the sustainability of general practice and the general practice model, but I’m not concerned about what the contract changes mean for our working relationships.
We’ve worked under the auspices of a national contract and local enhanced services for a long time, and the bulk of the relationship between a commissioner and practices has always been local. Obviously, over the years, we’ve seen a change in the national contract from individual practice-based contracts to bringing in practices to work at scale in a PCN.
My approach is about being fair, transparent, proportionate and being reasonable. We’ve done a lot of work over the last couple of winters with general practices around the pressures they’ve been facing and taking a view of the impact that’s had on their ability to do long-term care – the contract work.
Nevertheless, practices are worried about the 24/25 contract position and the level of investment they get from the ICB for enhanced services. That’s a live conversation but, like I said, we want to continue our good working relationships. If I go back to the three priorities, we’re not going to make inroads without a vibrant general practice model.
VV: Where is Derby and Derbyshire ICB on integrated neighbourhood teams? As it wasn’t prescriptive, there seems to be variation in the definition of it and how it links into PCNs. What’s your take?
CC: The definitions can be challenging, but sometimes that’s because we change the nomenclature. If we break it down and think about what we’re describing, we’re talking about multidisciplinary work that’s often around vulnerable and frail people in a geography and community.
We’ve got two things developing at the moment and we’re starting to work out how they come together.
PCNs to date are often about general practices working together, whereas integrated neighbourhood teams are community care services, social care and the voluntary sector working together. And often, that’s been in the place domain.
So, we’re mapping our PCNs and our place infrastructure. We’re having a conversation about where the broader partnership comes together. We’re looking to get clarity on who’s doing what.
We also have an initiative called Team Up. It’s done at PCN level and the approach is a multidisciplinary mechanism. Team Up takes all requests for home visits and there’s a multidisciplinary review of them. It’s about working with community nursing and care agencies to get the right response.
When I talk to PCNs, they often say that it’s made a difference. It feels important to member practices because it’s getting the right people to see those patients and freeing up time in the individual practices. We’re about two years or more into it and it feels like a really good exemplar of what integrated neighbourhood teams could be and where they could go.
VV: Historically, there’s been tension between practices and CCGs or PCNs when the independent partnership model feels under threat. The new contract says the PCN clinical director has to tell the ICB how the practices are fulfilling modern general practice to get funding, which puts them in a tricky spot. What’s the ICB role in supporting clinical directors?
CC: We are trying to achieve a GP provider model that takes ownership of the care it delivers. You’d expect any large provider to performance manage itself, taking account of where it’s doing well and its performance challenges.
At PCN level, it’s not surprising that we want to look at the performance of general practice at scale. Where there’s positive variation, how do you spread it? And where there’s negative variation, what do we think is behind that? How do we talk about it transparently and openly and how do we create an improvement plan?
Our role in this will be to help the clinical directors enter that space. It’s facilitating, convening, encouraging, supporting and nudging where it’s needed.
VV: You mentioned population health management as one of your key areas of focus, and data is obviously a big part of that. How do you plan to use data to make decisions for the population?
CC: The truth is, we have a huge amount of information already; the challenge is turning it into something we use for decision-making purposes.
We’ve got a lot of information around pathways – urgent and emergency care and so on – and we want to make it meaningful for geographical areas. Where we have alliances between places and PCNs, it’ll be really interesting to get information in a way that helps them make decisions to drive some of those historical challenges around workforce resource and so on.
VV: What’s the financial position of Derby and Derbyshire ICB, and how are you approaching that?
CC: I’ve been in the system since 2017 and Derbyshire has always had a challenged financial position. We’ve got a track record of delivering against deficit control totals over several years. In the last year, we’ll have delivered circa £130 million worth of financial efficiency.
It has been a challenging financial year in 23/24 and 24/25 will be equally challenging. When we approach it this year, we’ll collectively take a view around the drivers of the financial challenge and how we’re going to address that in the short, medium or longer terms. We’re open and transparent about it when we’re having these conversations with our NHS family and local authority partners.
We come back to the demands on the current model of care outstripping the resources. The work I described around the integrated care model – places working in PCNs and so on – is absolutely crucial to resolving a large part of that.
Shifting resources is one of the things that we’re going to have to think about seriously as a partnership. Where is the health need most present and are we going to alter differentially the universal offer of the NHS?
At the moment, we don’t differentiate—it’s universally free at the point of need—but surely in terms of health policy, we need to have a conversation about that. While it may still be universal—because that’s the NHS mandate—is there some proportionalism around that? And you have to be open about that conversation because it’ll have consequences.
VV: Finally, where do you hope to be this time next year?
CC: I would like to see the stabilising of urgent and emergency care and, if we’ve done that, I’m hoping that we’ll have made inroads into the waiting list position – both those waiting for secondary care services and in general practice.
I hope we’ll start to see some early evidence of the preventive work. That takes time, but for some things, like smoking and blood pressure control, results can be seen quite quickly.
