NHS Frimley is ‘on the edge of everywhere’ covering Windsor, Slough and Bracknell along with parts of Surrey and Hampshire. It’s this diversity the Chief Executive Fiona Edwards sees as a real strength. She discusses the current priorities for the ICB in an interview with Healthcare Leader’s editor Victoria Vaughan.
Victoria Vaughan: Can you give an overview of NHS Frimley?
Fiona Edwards: We talk about ourselves as being on the edge of everywhere. None of our local authorities are the same. Berkshire has six unitary councils – three in East Berkshire, a Labour-run council in Slough that’s in special measures, the Royal Borough has always had challenges on the money and is a Conservative-led council and then we’ve got Bracknell Forest which is probably one of the best councils in the country. It’s got outstanding children’s services, but again is staring down a black hole on money. Then we’ve got Hampshire County Council and Surrey County Council covering two of our places – Surrey Heath and North East Hampshire and Farnham. We’ve got some real diversity and, if you embrace it, it really helps you develop a clarity of purpose.
Frimley Health Foundation Trust (FHFT) was formed from a merger for the organisation to support and help transform Wexham Park Hospital which sits on the edge of South Buckinghamshire. It has a large population inflow from Slough, which is a younger, diverse population and more deprived. More than 150 languages are spoken, and it is the second youngest borough in the country which is really interesting. We’ve got the same as everyone else – in under 10 miles, there’s a difference in life expectancy of 10 years.
One of the really interesting stats is that 30% of our 800,000 population sits in the highest 10% of wealth and income brackets, and 3% sit in the lowest deciles of 10%. So the health and equality issues are magnified by the diversity of our places and also the concentration, and the power of the wealthy, in our system.
Without knowing it, the Wexham Park Hospital merger in 2014 was a real reach out from health to address and support an area of significant deprivation and diversity, and it worked. It shows how health systems can practically provide a construct, step in and make major change, and transform service delivery. We also know that those most deprived people will be twice as likely to have a long-term condition or attend our emergency department.
We have shifted to an absolute clarity of purpose to support and address those people that need it the most in terms of deprivation, which then leads to poor health outcomes and poor quality of life expectancy and that encompasses social care and mental health. That purpose informs our collective efforts with our nine local authorities, our 70 odd practices, our 16 primary care networks, our three NHS provider trusts, the three police forces and all the schools and education and voluntary sector.
Our strategy has been built through a digital architecture. We have a Connected Care programme that has run for about six years, which integrates health records and gives us a data platform. We also lead the Thames Valley and Surrey shared care record programme, which enables you to combine public health, social care and primary care data, but you have to get alongside your practices so they build the trust around sharing data for purposes other than first treatment.
We’ve got analytical capability that clearly shows overall our performance might be great, but the health and equality gaps prior to the pandemic were widening and mental health indicators mirror that as well. You can usually map into mental health, deprivation and safeguarding issues – as Marmot says, poverty drives health and equality.
We’re beginning to evidence that it drives inefficient use of public service resources which people can respond better to when it comes to transformation plans, rather than just saying it’s morally the right thing to do. It’s an economic driver that our local authorities really play into.
VV: What three things are you focusing on at the moment in your ICB?
FE: Our first priority is the urgent emergency care pressures, and that’s for every part of the system – including primary care, it’s not just about the emergency department (ED).
While FHFT has done well on recovery electives, the flow has seized up for well over a year, so we commissioned together a full-scale, system-wide urgent and emergency care review in the summer and we’ve developed eight priority work strands which use health and equality as our guiding principle and looks at having cells around mental health, primary care and integration across care pathways.
When Strep A hit, we had a 100% increase in out-of-hour responses. Our tracking shows that primary care had increased activity of 16% pre-pandemic and now that’s risen to 22% – so a GP will see four more people on average per session every day, and that’s possibly not taking into account the out-of-hours activity.
That’s our priority. Those indicators of ED and hospital being clogged up show how the system is performing – or not performing – as a total. Local Authorities are all signed up to that, primary care increasingly has signed up to that, and they are very much part of it.
VV: So you’re using the ED figures as an indicator for the system performance as whole?
FE: As a proxy while we’re building a similar framework to the Operational pressures escalation levels (OPEL) used in hospitals for primary care. So, there’s more physical equity, we’re still not there with mental health on that. And local authorities also see it as their problem as well as ours, as a consequence of us all not working optimally together.
That’s our top priority because it goes to the heart of our inequality strategy. That’s because many of those people in our ED or stuck in hospital come from our most deprived, disadvantaged communities.
The second priority is our strategy, which we are refreshing in the background because it’s so important to keep the relationships and everyone feeling aligned. We’re doing that as part of the integrated care partnership refresh. And, to be honest, that’s confirming what people buy into so it hasn’t shifted much. Our sense of common purpose is quite strong through all of these emergencies.
I was really energised by a recent meeting with 23 odd GPs who are all our PCN clinical directors (CDs) and place leads. In the new year, we put out a call to primary care to say: ‘How can we as an ICB really step up?’ At that point, we had ambulances queueing everywhere. And we had a really innovative response. That came from out-of-hours supply, which is run by all the same GPs, and Pharmacy stepped up in real-time to help with the internal pharmacy management in the hospital and capacity building for discharge. So we were getting that interplay going. Some practices opened on bank holidays over Christmas because everyone could see the data, and everyone could see it was a shared problem. We’ve come out of the worst two weeks of anyone’s health experience with a bit of a bounce actually, feeling that there are things we can do here. That will benefit our strategic framework.
The third priority is resources. We’re carrying huge risk, and so we’re actively reviewing that. FHFT has been very public about their forecast deficit position, which is unprecedented. Some of that is driven, not only by the pressures – particularly the ones that have just manifested themselves – but also by the implementation of a patient record system in the hospital. That is a huge operational deployment. This is where systems and the wider NHS need to really help our organisations to avoid taking the brunt of that by themselves.
Everyone underestimates the operational change task and the ripple effect across the whole system of referral management. It’s a fabulous system, and it will yield lots of benefits, but you’ll get a performance dip and a productivity dip.
We’ve also got a reinforced autoclaved aerated concrete (RAAC) plank issue at Frimley Park Hospital which was built at a time when they used concrete that basically rots away after a few decades. We’ve got capacity restrictions there which again drives costs and reduces productivity because we never have full availability of theatre capacity. That is affecting our financial position and the use of agency staff because of the total flow blockage that I described, which has been in Frimley for a long while. We’ve got 200-odd escalation beds open, and that’s doubled from 100 in the last month. So, there are some unique factors to FHFT, but also there are some underlying factors that would apply to most organisations in the country in terms of bed blocking and that kind of thing.
VV: How are you approaching health inequalities in your area?
FE: Frimley’s original strategy in 2019, pre-pandemic and confirmed now through the reset, is about addressing health inequalities and working on the wider determinants of health. It is right that that should be owned by the Integrated Care Partnership (ICP) – it is not a health construct. That is underpinned by data. We have a thriving citizens panel of about 1,000 people. We checked it directly with some of our residents, and we also took in a professional, clinical engagement to inform that strategy, which is being refreshed now. It’s a much wider engagement of local authorities this time who are confirming that direction of travel as well as embracing it.
The six ambitions within it are the best start in life, so children, young people and families, pre-birth, maternity. Our first bit of business as an ICB was to sign off our children’s strategy, and we have a resource in the ICB dedicated to children and young people which includes addressing the increased mental health prevalence and neurodiversity demand.
Then we talk about living well. That covers things like blood pressure and hypertension monitoring, which took a backwards step during the pandemic.
The third ambition is something that we’re just trying to work out the name of, which is about engaging differently with our citizens around living the healthiest economically independent life as possible. That really draws in the wider economic strategies of the local authorities and it also draws in employment.
Then we have three other underpinning ambitions, which are crucial. We have a specific ambition around being an ICS that focuses on developing leadership capability and having a culture across public service and the voluntary sector that really connects well with citizens, builds collaboration, and understands complex system working.
The last two are around people. Our approach around workforce is to recognise that we’ve got 800,000 people and we want to create a virtuous circle of development employment from schools into the public service system, health and social care. We’ve got a system people board that’s been running for a while. We’re leading a temporary agency programme for Buckinghamshire, Oxfordshire and Berkshire West system and for Surrey Heartlands as well as our system. That is looking at a much more controlled market around locums to help manage the cost pressure. This compliments the whole approach to workforce. One of our big issues is that we do need the national workforce plan and approach, and it needs to embrace primary care. But we don’t need a detailed prescription of how you then implement it because our learning shows you’ve got to have that flexibility to do it locally.
VV: What’s your view of primary care in your area and how are you supporting it?
FE: We have real fragility in our primary care networks and practices, so like everyone else we’re having to play quite an active role as an ICB in supporting the resilience of practices. The strength of our clinical leaders in our primary care networks, our 16 clinical directors, is outstanding. People think it’s all about FHFT, but it’s not. I was a Provider Chief Executive for 20-odd years and what I’ve really been struck by is the limited understanding of what goes on among people who don’t work in primary care. Honestly, we’ve got some stellar performers, not least in North East Hampshire and Farnham. They were a vanguard, they did lots of work on integrated care teams. As did Surrey Heath outside the vanguard process – a lot of the Fuller review stuff drew on that.
We’re in the territory of reimagining and redefining primary care. I’m really struck by the role our retail pharmacies have played along with our PCNs. We’ve had some vaccination centres almost totally run by pharmacists, not doctors. You’ll have people playing to their strengths, depending on the mix of provision we’ve got, whether it’s commercial, voluntary sector, as well as health and social care providers. Your GP practices still see 90% – it is the front door of the health service – so that’s an aspect we need to own, celebrate and respect. But relying on doctors to manage workforce flow isn’t the answer.
The PCN work has really helped widen the workforce within primary care. Our thinking is that it’s not just GPs; it will be paramedics, allied healthcare professionals (AHPs) and pharmacists as well. I’m not sure that the Fuller review totally takes us into that wider definition territory because we’ve still got a delegation of some primary care commissioning coming, such as dentistry.
If you look at doctors per head, we’ve got patches that have got really high GP numbers which map onto the wealthiest areas, whereas Slough is one of the lowest for GP numbers but is really strong in pharmacy. That pharmacy mix isn’t all health employed – it’s retail pharmacy. I’ve got a fantastic chief pharmacist, who is really mobilising a wider community construct around this, so we’ve got to embrace the complexity and not try to oversimplify it. I believe in diversity being a strength rather than a weakness, and we do have some incredible talent, but we’ve also got some people on the edge of falling over. We’ve got the full spectrum, but people do step in and help each other.
VV: What role does the ICB play in terms of supporting the areas which are ‘falling over’?
FE: We have a safety role and a quality oversight role, which means that we take a convening role where we have real resilience issues to support practices. We might put in support, or we will work with other primary care colleagues for support.
Our ICB board has four GPs on it, so we’re fortunate in that. Our chair Dr Priya Singh comes with clinical background as a former GP. I’ve got two partners, and our chief medical officer is a GP, so alongside our three secondary care providers and three local authority members, we are really clear in terms of how we lead and think in all our decision-making. We take account of primary care in that broadest sense alongside all our other priorities, and I meet with the 23 CDs and place leads. I join our Director of Primary care who reports to me. She holds a portfolio and supports the development of PCNs. We look at the investment required to do that, even in strained circumstances, and weigh up the benefit of continuing that development so people can innovate. It’s central alongside local authorities and the voluntary sector and citizens. We’ve got to fold this all in together.
VV: Are you fairly advanced in your work set out in Fuller around implementing integrated neighbourhood teams?
FE: When you talk about the Fuller review I would say we’re doing it, but the risk is turning it into a blueprint that is then applied and used for performance management. The national tendency is always to do that. There are some real downsides to the model of the ICB because it created a traditional NHS construct for channelling treasury money that doesn’t yet understand complex systems. The best way to make transformation happen is to think small and let it grow and develop.
Through Connected Care, we were working with one or two practices, two years ago on anticipatory care. Using the data, they could see people with diabetes and the number of interventions being made, and they were able to really shift their practice on targeting resources. Rather than driving that through we let people see it and used our PCN CD network to get near to full coverage.
We were having the debate about whether to suspend QOF or not, and as mentioned we’re developing an alert tool now, similar to OPEL, using real data, drawn from EMIS, connected up. That came through a great discussion with our GPs. They’re all saying, ‘We’re silly if we don’t join in with this because we don’t have an argument to respond to The Daily Mail without it’. And that’s GPs, I didn’t have to say it.
The transformation model has to be building that digitally connected architecture from the ground up not top down. I really worry about the national way of thinking about this. We’ve got to work with what we’ve got rather than trying to create a fancy system. Let people try things, experiment.
The Fuller review drew on what was going on in lots of places and so there’s a big chunk of Frimley stuff in there. We’ve got two places that are really clear on their integrated team models, which will have mental health and social care in it, and then we’re developing in other places. There is a challenge with providers of community and mental health services, and you have to be prepared for the different paces. There’s nothing I can disagree with in the Fuller review. How you manage and develop it has to recognise that we’re a human system with differential models everywhere.
VV: Where do you want to be in a year’s time?
FE: We’ve only really been in operation in this form for six months. We’ve had to really work at a sprint on getting organised. In a year’s time, everyone will understand decision-making processes, the components of our system and our operating model and the flows. And when I say operating model, it’s not a neat and tidy picture. It’s just the roles of all the players in the system and that the ICB will be much clearer about its role in managing the health investment and plan into the wider ICP.
Our ICP assembly, which we’ve described as a public service assembly, will be much clearer and better at articulating our re-set strategy and the programmes of work.
We’ll have a different public dialogue going, and underneath that, operationally, we will have a winter plan. We’ll come to April and we will have a year’s flow plan, if you like. And in a year’s time we’ll be able to look back and say, ‘Actually, that felt a better planned and delivered year’ rather than constantly reacting.
We know we have bank holidays and school start and finish times but it’s about converting it into a planning framework and then sticking to it. That’s where the ICB can really help create a framework. We’re much more into the operational flow management than what came before.