Mary Hutton, chief executive of Gloucestershire ICB, talks to Healthcare Leader editor Victoria Vaughan about how joint working is transforming patient care and the plans to further the progress made so far.
Victoria Vaughan (VV): What are the unique characteristics of Gloucestershire ICB?
Mary Hutton (MH): Well, Gloucestershire ICB is one of the smaller ICBs, and we’re a fairly simple construct in that we have one county council that is coterminous with the ICB, one acute trust and one community mental health trust.
We were working together for quite a period of time prior to the formal ICB setup. We’ve got six integrated locality partnerships, 15 PCNs, 64 GP practices and 67 dental practices.
We also focus on our independent social care providers – there are about 5,500 of them – and they’re really keen to be more involved with us. And we’re seeing more and more that there is a need to support the voluntary sector.
In our people structure, we talk about 7,000 employed workers in the voluntary sector in Gloucestershire and about 14,000 volunteers. But, of course, there are many more smaller voluntary sector organisations and groups working across the patch. So, we’re trying to see how we can bring all that together and make it work effectively.
VV: What are the top three priorities for Gloucestershire ICB right now?
MH: There are three main pillars in our health and wellbeing integrated care partnership strategy.
The first pillar is about making Gloucestershire a better place for the future. It’s about looking at prevention, working with the voluntary sector and building community resilience.
Pillar two is about transformation. In there, we’ve got locality working, workforce, inequalities and the whole of our transformation around clinical programmes and urgent care.
And the third pillar is getting services right for the patient today. So that’s about delivering on urgent care and mental health etc.
VV: How is Gloucestershire ICB approaching workforce?
MH: We have a group that is working across the system. We have an employment stream led by the county council, which comes through our integrated care partnership. We have a whole lot of ICB staff involved where we’re working with schools to get more people into employment.
In Gloucestershire, we have a very flat working age population and a highly significant growth in the older age population. We also have an issue where a lot of young people move out of the county. So, we’re developing opportunities and then encouraging people to see careers ahead of them in the county. We’re doing work with the university and colleges, particularly in areas like dental, for example.
We also have a group working on things like a health passport. We have a workforce wellbeing hub that’s set up across the system to provide support to people. So, there’s a lot of joint work.
We’re also doing lots of work as a whole system around 2050 vision and looking at cybersecurity. We have GCHQ in our patch so, obviously, we need to build on the whole IT agenda across Gloucestershire.
We’re just about to launch a campaign, which we have done before, about the benefits of working in Gloucestershire. The last time we did that, it seemed to work well particularly around attracting primary care staff into Gloucestershire.
VV: How do you rate patient access to primary care in your area?
MH: Appointments in primary care are up 26.2% from 2019. That’s a huge amount of extra capacity, which obviously isn’t fully funded in the system.
We have had good recruitment of GPs in Gloucestershire. Compared to 2019, we are pretty flat for GP numbers. We’ve seen an increase in additional roles and an increase of about 8.5% in nurses in primary care and we’ve got a very big social prescribing provision. So, there is an increased capacity in primary care in Gloucestershire, but we did not expect to be dealing with this level of additional demand, so that is a problem.
We’re now trying to understand where that demand is coming from so that we can support primary care by redirecting some of it to alternatives, such as pharmacists.
VV: What’s your relationship like with primary care as an ICB? How would you rate the engagement at both practice and PCN levels?
MH: We are very fortunate that our primary care is really strong in Gloucestershire and we have good support when we introduce new initiatives like FIT testing and primary care guidance. They really work with us.
So, in return, we’re trying to support primary care. We’ve had quite a lot of new premises developments over the last number of years, which have been positively received by primary care. We have invested in a team who work with primary care. As well as dealing with contracts, they work on primary care, locality, and place development.
We are aware, though, that primary care is facing significant financial challenges and part of that is the challenge around capacity. We’ve seen an increase in on-the-day appointments, and therefore we’ve seen some length of time wait for routine appointments. And obviously, doing 26.2% more is a significant challenge.
VV: The problem is that urgent on-the-day pushes out continuity of care, which has been proven to have better outcomes in the long run. Northwest London is looking at setting up same-day access hubs, which is quite controversial. Is that something Gloucestershire ICB is looking at?
MH: We’re more in the camp of continuity of care. You might have seen the recent study by the University of Cambridge and INSEAD Business School, which showed that continuity of care reduced costs massively. We need to be careful that the model fits the needs of our population. We have a mixture of rural and urban populations, and I don’t see how that [same-day access hub] model works in a rural population.
Since 2019, we’ve seen a much-reduced demand for secondary care and urgent care, so we’re certainly not going to jump into a new way of working until we’ve got a tried and tested model for it.
Obviously, we’d have to understand how primary care manages increased capacity next year if their funding isn’t sufficient to meet it. But at this stage, our primary care is really responsive.
Our primary care really took on board the Productive General Practice work that was available to them a number of years ago. And we do quality improvement projects at PCNs. The opportunity to really understand the needs of your population and to tackle some of them brings energy into primary care because it gives them the ability to tackle some of the difficult issues. So, our practices are very engaged in quality improvement projects and really want to extend that work, which builds into the work we’re doing around the Fuller implementation.
VV: Do you have Fuller integrated neighbourhood teams in Gloucestershire yet and, if so, what do they look like?
MH: In terms of integrated neighbourhood teams, we have them in our community trust and, obviously, they work closely with practices already.
In two areas – Cheltenham and Rosebank in central Gloucester – we’re piloting what truly integrated teams look like across healthcare, social care and the community trust. We have a joint director for the ICB and the community trust to help us understand how we wrap general practice and community services together around a population.
In Cheltenham, for example, we are using frailty as one of the themes and working through how it could be better.
We are focused on understanding the inequalities in our area. In Gloucestershire, we have a good life expectancy – 80 years for male and 84 for females – and an average of 67 years in good health. But there’s an 11-year difference in healthy life between our wealthier and least wealthy areas. So, we’re trying to think about how we address that huge disparity as we work through those projects at a PCN level.
And we have a PCN group in our localities. There are six localities which work around the district – we’ve got a two-tier system – with the voluntary sector. Together, they’re taking forward some of those projects on the wider determinants of health. So, we’re seeing a significant change in how we work across our system.
VV: You’ve only got a small amount of funding to address health inequalities, so are you changing the way that things are funded in your transformation work?
MH: Yes. We have clinical programmes in Gloucestershire – one for cardiovascular, orthopaedics, cancer, etc. – with patients, consultants, community staff, and primary care. They’re agreeing pathways and talking about what should be moved upstream and what the voluntary sector can do.
For example, in pain management, we found real success in reaching out to the voluntary sector and setting up some alternatives for children and adults in their local areas. This has helped pain management, reduced prescribing significantly and given people a better quality of life.
The other thing we’re working on with our health and wellbeing partnership is exemplar themes to try and bring everybody moving in the same direction. So, this year, we picked employment, smoking and blood pressure monitoring. People in the voluntary sector are working with people at the lower end of blood pressure. Then also it’s thinking about if people are at crisis point, what alternatives can we provide for them in terms of exercise, classes and advice, etc.? I’m trying to get a joined-up position in each of our localities so that we know the issue and our response.
VV: The board papers suggest that Gloucestershire ICB’s financial position isn’t as bad as elsewhere. However, the funds for delegated commissioning of pharmacy, optometry, and dentistry weren’t fully spent. Could you discuss that?
MH: Well, we have a balanced plan in 23/24 but we have a very challenged plan for 24/25 so we’re not near balanced yet.
In dentistry, for example, we’ve been working on an oral health programme with the region and other ICBs across the region. We started rollout in January 2024 so, clearly, we have an underspend for 23/24 but we have plans to commit quite a lot of that underspend in 24/25. We’re not seeking to hold a dental underspend to offset other spends in our system and we’re very clear about that to our dentists.
And we have an enormous transformation programme on urgent care across a whole system with a lot of external resource. We’ve been on this track for about six months, and we’re expecting to see quite a radically changed urgent care system by the time we finish.
We’re doing work to try and develop savings plans across the system because we haven’t got many easy options left.
VV: Where do you hope Gloucestershire ICB will be this time next year?
MH: We are hoping that the work we’ve done on transformation around urgent care will stop us having to talk about urgent care all the time. And obviously, we have to deal with elective, cancer, and mental health.
We hope to continue the work around access in primary care and resolve some of the issues to make primary care more comfortable for our practitioners, which is very challenging at the moment due to the increase in demand.
Also, in our health and wellbeing partnership, we’re talking about how we accelerate some of our work together and set up some sort of structure around our infrastructure with the voluntary sector.
