Dr Caroline Trevithick, chief executive of Leicester, Leicestershire and Rutland (LLR) ICB tells Healthcare Leader editor Victoria Vaughan about the priorities for the area – and a new model for discretionary investment in primary care.
Victoria Vaughan (VV): Can you tell us about Leicester, Leicestershire and Rutland (LLR) ICB and its unique characteristics?
Dr Caroline Trevithick (CT): We’ve got two main trusts – University Hospitals Leicester (UHL), which is our main acute trust, and Leicester Partnership Trust (LPT) which has responsibility for mental health and community services. So, from an NHS perspective, it makes us quite neat.
We’ve got one upper-tier local authority and two unitary authorities.
We have Leicester city, which is the UK’s first plural city. That’s where ethnic minority groups are the majority. So, we’ve got some wards in the city where 80% of residents are from ethnic minority groups. About 43% of Leicestershire’s population is from Asian, Asian/British ethnicity. Leicester city is the most densely populated local authority in the East Midlands, with over 5,000 residents per square kilometre. And 35% of Leicester city residents live in England’s 20% most deprived areas.
And we have Rutland, the smallest county in the country, and very rural. Then you’ve got the county, which is predominantly more rural but also has market towns and areas of deprivation.
So, you can start to see how the health needs and life expectancy of the 1.1 million people we serve vary across those three places. Health inequalities are one of our most significant challenges.
VV: What are the three things that you’re focused on as an ICB at the moment?
CT: The number one risk on our board assurance framework is health inequalities. When you reflect on the demographics of our population, you would expect that to be high on our priorities. Our five-year plan’s number one pledge of the 13 pledges focuses on health inequalities and delivering health equity. So, we’ve got activity and resources focusing on where it’s going to make the most difference.
VV: The money you’ve got for that kind of work is quite minimal, and people can often see the rationale but don’t want to lose their budget. How are you managing that?
CT: Shifting the money is one of our biggest challenges, but realigning the focus to prevention is a challenge that every ICB across the country is grappling with. It’s really ensuring that we’ve got services and, where we have got investment, it needs to demonstrate how it’s tackling health inequalities – that’s got to be a driving factor.
So, when we’re thinking about our elective care work and managing our waiting list backlogs, we’re looking at that through our health inequalities lens. We don’t just come to things from a numbers-based perspective.
We definitely haven’t cracked this, but it’s our biggest priority, so it’s at the forefront of our minds and that of our system partners. So, if you were doing a similar interview with UHL or LPT they would be able to demonstrate where their organisations are addressing health inequities.
VV: So, the number one priority for LLR ICB is health inequalities. What are priorities two and three?
CT: From a strategic perspective, it’s creating the conditions for success. Our board has been working on it over the last few months. We’ve been thinking about how we might organise ourselves in a way to create the conditions for transformation.
We know that the NHS needs to transform to be able to focus on health inequalities and prevention, and our guiding principle is associated with the right person, the right place at the right time – it’s a focus on people and not organisation. So how do we come together to ensure that we’re delivering on those outcomes for people? It means strengthening the collaboration between partners and stakeholders. Aligning our plans is a good start, but we want to move it more into collaborating and transforming by pathway.
As a fairly neat ICB with a small number of health providers, we can align ourselves through the health and wellbeing infrastructures at Place, which allows the local authority footprints.
So, we’ve got some really positive examples of how we’ve worked in mental health and learning disability and autism to come together as a system led by our mental health trust to bring partners together to deliver on the needs of the population. We’ve seen some dramatic changes in outcomes for patients, particularly those with learning disabilities – reductions in hospital stays where we need people to stay in the community, but also increases in health checks. By co-ordinating ourselves around a collaborative arrangement that includes health providers, local authority, the voluntary and care sector, and the community sector, we can then deliver things differently based on the needs of the population.
We want to move further and go into different pathways. Our elective care pathway is starting to work in the same way, and it’s delivering some great outcomes around reducing our waiting list. The other two chief executives in the patch and I are working on what needs to be done to support the urgent emergency care pathway. That’s complex – it presents every system with challenges – so we want to ensure that we’re coming together to deliver those outcomes for patients. We all acknowledge that we need to transform to be able to do that.
VV: In terms of the urgent emergency care pathway, how many of those conversations are around what needs to happen in primary care?
CT: A lot. If you break down the pathway, we’re thinking pre-hospital, hospital and post-hospital discharge. We’ve got a lot of work already in the pre-hospital space to keep people away from the front door, to triage them and take people off the ambulance stack. To do that, we need to ensure that we’ve got a robust primary care service to hold those patients. It’s the same with virtual wards – the interface between hospital and community is critical to keep people in the community.
It’s going back to what I said about the right person at the right place at the right time. We’ve got to make sure that we’ve got the right activity and the right access to primary care to support that intent. And we need to transform because our services aren’t set up that way. Our services and resources are about managing the here and now. To get us into that transformation space, we need to unlock some of those conversations so that resource is made available where the patients need the service.
VV: And what’s your third priority and what are you doing in that space?
CT: It’s workforce. The role of the ICB is to get into the space where we talk about transforming our workforce.
During COVID, we had an MOU between organisations to allow staff to work in different areas depending on where the need was and building on that is critical. If our resource follows the patient and we need the resource in the right place, then we need to be able to ensure that our staff can move as well. That doesn’t necessarily mean people leaving one organisation to start at the next. A passport type of approach is critical to support them to flex, depending on need.
Transforming our workforce to enable an agile workforce is one of the tenets of the people board that we have in place, which has representation from healthcare. Our chief people officers are working closely together to understand our recruitment and retention.
Retention and supporting innovative employment models are critical aspects for us. LLR is in our second year of being a people retention exemplar site, and we’re now moving into primary care.
Being a people retention exemplar site has allowed us to look at the key drivers for people leaving the system. Moving into year two, we’re looking to place key roles to drive that forward for primary care so we can understand the retention challenges. Then, we’ll use the data to improve and develop a programme of resilience and sustainability to address poor retention in primary care. Doing that on an individual practice level is quite challenging, but doing it collectively as a system might get us into a very different space.
VV: How do you go about that? Practice sovereignty is hard enough for PCNs to navigate, never mind the ICB. So how will you work with primary care to achieve the changes?
CT: Relationships with primary care are critical. It helps that this isn’t the first thing we’ve done with primary care in LLR.
For example, we put in place a workforce hub – or workforce pool – to support winter pressures in general practice. It’s classed as a digital flexible multi-professional pool and has enabled us to onboard people via one of our provider trusts to support system surge to primary care.
So, it’s building on the relationships we’ve got locally with our PCN leads and our individual practices to demonstrate the benefits of doing this together.
I don’t think we’re coming at it with a sense of naivety – we’ve got 126 practices and 26 PCNs to negotiate with – but we’ve got clear examples of where we’ve done it in the past and supported them from a workforce perspective. It started in covid, where we were able to support them with additional staff for vaccination programmes. So, LLR ICB has got a bit of a history with supporting practices around workforce.
VV: Would you say your access to primary care is good or something you need to improve? And how are you approaching an integrated neighbourhood team space?
CT: In terms of access, we’ve seen increases in the numbers of appointments. Looking at average appointments per month, it’s increased by 150,000 between 22/23 and 23/24 – a substantial amount.
But LLR is still seeing the pressures. The primary care member on our board has talked about how, even with those increases, patients are still struggling to get access into primary care. So the need is increasing, but so too is the need to have a different conversation with our public about where else they might go.
Pharmacy First, for example, has been launched. How are we going to maximise that to try and triage away from primary care? We’ve spent a lot of time thinking about triaging away from ED into different services, and we’ve got to have the same approach to thinking about primary care as well.
I think people are now more used to seeing somebody other than a GP than they were five years ago, but it’s definitely still a challenge for us.
One of the things we have done to continue engaging with primary care is to ensure that LLR has got good GP representation in some of our governance structures. Going from clinical commissioning groups (CCGs) into ICBs, there was a danger that we’d lose all of that general practice knowledge and experience. So, a number of our clinical leads are GPs or pharmacists, and they’re responsible for some of our pathway development. It’s positive that we’re keeping that engagement in there.
From the integrated neighbourhood team perspective, our Place leads are GPs. We’ve got a Place manager lead, buddying up with a Place clinical lead, so that we can start to think about how we identify those priorities for the neighbourhoods. It’s been led through the health and wellbeing boards in each of the places.
And then we’ve got a Fuller steering group to make sure that we’re pulling all of this together. We’ve got multiple examples of where we are focusing on the things that are important to that population at a district council level, and then a city and Rutland level in the two unitary authorities.
VV: Could you give an example?
CT: An example would be the borough of Charnwood, a district that includes Loughborough. There’s some deprivation, quite a lot of homelessness and challenges around mental health.
We’ve got priorities around mental health, targeting homelessness, suicide, cost of living, teenagers, loneliness, dying well, dementia and carers. That’s been identified specifically through those integrated neighbourhood teams working with the local authorities. From a Leicester city perspective – because the challenges for that community are very different – there are priorities about cancer, screening, hypertension, weight management, and women’s health. So, that’s a different flavour of need.
That’s where LLR’s work with the PCN is critical. We’ve got Place leads who are GPs and PCN engagement at neighbourhood level. We’re supporting the work using ARRS roles to work collegiately and in collaboration with our system partners on delivering those local priorities for people. And when you speak to our health and wellbeing boards, a lot of the energy is with the engagement with primary care.
We’re also working closely with primary care on a model that Dr David Shepherd (clinical lead for risk stratification in the LLR integrated care system) has been working on. It goes right back to the health inequalities stuff.
He has been working on a different funding approach – an innovative model for discretionary investment by ICBs in primary care. It’s been recognised nationally and internationally for the work around adopting a different methodology to address historical underfunding of practices based on greatest need.
VV: Is LLR looking to implement that?
CT: We’re still working on elements of it. We’re working really closely with primary care on that. We’re really proud of the model.
I was speaking to a colleague in another ICB earlier today, and they’re adopting it too. It’s a really positive model, but adopting it takes time – any kind of change takes time.
VV: Can you speak about the financial position of LLR ICB? Where are you right now, and what do you hope to do?
CT: Our financial position is that we’re looking to deliver a £61 million deficit by the end of the year. It demonstrates how hard it is for organisations to deliver care within their budget – we wouldn’t be overspent if it wasn’t challenging.
But it also drives the conversation about transformation. LLR has got to think about how we do things differently – not just us, but in partnership with local authorities. It’s going back to those integrated teams, and all the areas of prevention they’re focusing on – the right thing to do is to support those pieces of work and scale them.
But our financial position at the end of this year presents us with a huge problem going into next year. You know, it’s storing up problems for us in the future if we don’t transform. For me, that’s the critical thing.
VV: When it comes to partnerships, do you feel there’s progress in moving away from silo working? Do you feel collaboration is tangible and more than just a good idea?
CT: In LLR, we have been trying to work in greater collaboration for longer than ICBs have been in creation. ICBs have given us the infrastructure to be able to move it forward in a different way. So, the short answer is, yes, we’re seeing some great collaboration with some tangible outcomes for patients. And we want to build on that.
Do we think we could go further? Yes, we do. Do we think we could do more collaboration across primary and secondary care? Yes, we could. But we’ve got the building blocks to be able to do that, I think. And we’ve got the intent to do that.
VV: Thinking about the future, where do you hope your ICB will be in a year?
CT: I hope to go into 25/26 being able to demonstrate where we’ve got tangible differences around our health inequalities. And that we can point to greater investment for prevention than we have now.
So, it’s moving the dial just a little bit more to start turning the tide on dealing with everything from a reactive perspective. It’s being able to get a bit more upstream of some of the challenges we’ve got and being able to evidence it better than we can today.
