Paul Bentley, chief executive of NHS Kent and Medway, tells Healthcare Leader’s editor Victoria Vaughan about how a new medical school, golden hellos to GPs and partnership working are part of the integrated care board’s plans for the area.
Victoria Vaughan: What are the unique characteristics of your integrated care board(ICB) area?
Paul Bentley: Kent and Medway is really diverse. What makes us unique is the range and diversity in such a relatively contained geographical area. We serve 1.9 million people, and within that, there’s a life expectancy range of 17 years, which is pretty extraordinary. We’re an integrated care system (ICS) that runs from the outer London boroughs to the coast of England and the border with France. There’s a perception that Kent is leafy, wealthy, and affluent – Royal Tunbridge Wells and Sevenoaks are definitely cut from that cloth – but we also have areas of significant deprivation.
VV: What three things are you focused on?
PB: We’re concentrating on partnership. You cannot deliver as an ICB unless you work with people. You cannot do unto people.
We are still recovering from the pandemic in terms of the impact on elective waiting lists and the demand on primary care services, and the initial evidence suggests that health inequalities have widened because of the pandemic, so we’ve got to navigate through that.
And then number three is being very clear about setting the ambition. We’ve gone through the setup phase, and we’ve put in place the right steps, the right governance and the right processes. We have to be really clear about what differences we want to see as a result of the ICS infrastructure.
VV: The sustainability and transformation plans that came before ICBs were criticised as not being very inclusive beyond the NHS. How has that been historically in your area and how are you moving forward?
PB: The NHS is 75 years old this summer. Isn’t it remarkable that it has taken nearly 75 years to realise we couldn’t do it on our own?
So very early on in the life of the ICS in Kent and Medway, we adopted the Robert Wood Johnson model of health improvement. It recognises that treating ill health is only part of the solution. A greater part of it is where you’re born, your education, and your socio-economic dependencies.
If you recognise that health can’t do it all – and we ought to be in the prevention game – it becomes easier to engage with partners. Our integrated care partnership board has three equal partners: Kent County Council, Medway Local Authority and the ICB. We operate as a triumvir.
We have the directors of social care as members of the ICB board – one from Kent and one from Medway because we wanted to have both around the table. They’ve been insightful in terms of having the discussion. Then, with the increased funding that came into the budget for the delayed discharges before Christmas, we’ve worked hand-in-glove with our partners and used the Better Care Fund to drive some of that collaboration and partnership.
It’s not perfect; we have not reached the ideal point yet. But it is better than it was before. I welcome the statutory definition and framework that underpins how we work. And that’s been taken strongly and helpfully by our colleagues in local authorities. We built the governance, and now we’re setting the ambition. And part of delivering the ambition is about maturing those relationships.
VV: How are you progressing on the four core aims? What do you see as the aims for NHS social economic regeneration?
PB: I’m not going to duck it, the fourth is the least developed of all four aims. When I talk to colleagues, ICB chief execs, they recognise that.
In Kent and Medway, we recognised that our local authorities were doing a great deal in this space. The requirement to bring economic growth and economic development to an area is something that councils have worked on for decades. So we’ve said, ‘Rather than go back and reinvent the wheel, why don’t we see what we could add to those debates rather than replace it and rip it up and start again?’
In the integrated care partnership board chaired by our local authorities, we’ve had discussions with the existing economic development forum. And then we’ve started to say: ‘So how can we go faster and how can we go further?’ That feels like the right thing to do.
In terms of the first three, we’ve had a relatively long-running population health management programme where we’ve worked with public health and developed the principles of what good population health management looks like.
In Kent and Medway, we have four health and care partnerships, which are geographically based and vary in size significantly. They are all heavily invested in population health management and each has the director of public health – or their alternative – involved in their development. We’re trying to use the data to drive what we choose to do in terms of narrowing health inequalities.
VV: How are you tackling health inequalities in your area?
PB: On the April 1, the ICB for Kent and Medway was allocated £3.9 billion to support health and care in Kent and Medway. So what we have to do is spend every penny of the £3.95 billion wisely. We definitely have to shift the narrative away from treating to preventing ill health.
There are choices and decisions to be made. I’m encouraging an approach which is that this is the amount of money we’ve got, so let’s have the conversation to make sure that we invest it rather than spend time talking about what we haven’t got. You could use up a great deal of energy and capacity on the second, and I’m not sure it’s terribly helpful.
VV: What’s your view of your primary care?
PB: We’ve got brilliant people working in primary care – I mean, genuinely brilliant in terms of their diligence, innovation and how we do things. We know from the data that in Kent and Medway, we are providing more appointments in primary care than before the pandemic. But the level of demand is outstripping the level of supply.
My daughter is a GP, so I do get some of this at home in terms of what it’s like to be on the front lines. She doesn’t work in Kent and Medway, which is helpful.
So, what are we doing about it? We’ve got 42 PCNs, and we must continue investing in their development because they are an important part of our system. They are at the table with our health and care partnerships, and that’s helpful. We’ve got to continue to invest in digital work and work in our workforce.
We’ve run a pilot scheme whereby we’ve introduced some education hubs in the most challenged parts of our GP community. We’ve introduced some golden hellos to people who will come and work here, retention payments. So we’ve got to continue to do those and, if possible, scale them up.
And we’ve got to work on the demand so that it is met through the right gateway. We work with a great local pharmaceutical committee in Kent and Medway. We’ve invested in the technology that allows the community pharmacies to process the prescriptions without the patient going to a GP. That’s a significant investment, but we know it makes a difference to the people we serve.
VV: Who is the workforce pilot for, and who runs it?
PB: It’s for anybody in primary care, not only GPs. They’re geographically based and run by primary care for primary care.
Primary care can be quite a lonely place. When I talk to the tutors who work out of those hubs, there’s a sense that one of the important things is bringing people together and having a conversation. Otherwise, because the demand on primary care is so great, it’s very difficult to have those conversations.
VV: Are golden hellos and retention schemes for everyone in primary care? And has it worked?
PB: Initially, they were for GPs in the northeast tip. In Thanet, we have some of the lowest ratios of GPs per head of population in the country, so we have to do something to attract and retain them.
Some elements have worked. We attracted more GPs, and it has helped us engage well with the local authorities. For example, when we talk to people about becoming a GP in Kent or Medway, the perception is that it’s an expensive place to live. And schooling is complex in Kent, in particular, because we still operate the 11 plus. So we worked with the authorities and said, ‘Could we make sure that there is a housing offer for people who come and work here as a GP? Could we make sure that people understand what the school options are?’
So we attracted more GPs and worked well with our local authority colleagues. But is there more to do? Yes, absolutely. I’d love to say we haven’t got a single GP vacancy in Kent and Medway, but it wouldn’t be true.
VV: Kent and Medway has its own medical school now. How will that help?
PB: It’s great. Until three years ago, you had to leave Kent and Medway to do your medical degree.
Much of the data says that people like to work where they trained. So I’m optimistic that, in a few years, those people who grew up in Kent and Medway will choose to stay and become our GPs.
When I go and talk to colleagues in Kent and Medway Medical School, that’s the data they’re getting, which is brilliant.
VV: How is your current engagement with primary care working?
PB: It works at various different levels.
We have a series of clinical leads who are drawn from our GP community. For example, our clinical lead for mental health is a GP, as is the clinical lead for learning disabilities and the clinical lead for hypertension. So that’s one level of engagement.
And we took a decision when we set up the ICB to have two GPs on our board. We appointed two deputy chief medical officers – one from secondary care and one from primary care. And we chose the one from primary care to be somebody who, again, is a GP in the system.
We’ve got 42 PCNs and we facilitate them coming together. And we’re also really lucky that we have a Kent LMC – the LMC represents the whole of Kent and Medway, it’s just that it predates Medway existing as a legal entity. We work closely with the LMC on issues spanning the entire ICB area.
VV: The Health Select Committee released its report recently in which it said that the Government should ensure each ICS had fair representation of everyone, including social care. From what you say, it sounds like you have that covered?
PB: Partially. But there’s a tension in that the people on our board are members of our board – they’re not there to represent a particular group. It’s an important distinction.
We have two people from local authorities who may be members of a unitary board, but they are not there to represent it – they are there to bring their experience and perspective to improve the board debate.
VV: It’s going to be a year on from the Fuller stocktake in May, and I understand from other ICBs that people see it as the blueprint for their primary care plan. There’s also a grey area over PCNs becoming integrated neighbourhood teams, and that’s very different in each ICB. What’s your view?
PB: I’m quite lucky because Claire Fuller’s ICB is a neighbour of ours. So I have the benefit of meeting and talking with Claire frequently, and the vision she set out for primary care is one that I recognise and support.
What we’re doing in Kent and Medway is to take Fuller as a starting point and build something that is Kent and Medway specific.
I think there’s an open question about neighbourhood teams. The former Secretary of State for Health, Sajid Javid, made a series of statements about what the future of the GP workforce would look like. I think that the primary care recovery plan will be about access. I don’t think it’ll be about structural change.
It’s really clear in Kent and Medway that a partnership model is, or was, attractive for some but not others. When you talk to GPs who have qualified more recently, some have no desire to be a partner. So how you make that integration with community health services is an open question.
And we’ve got a community trust in Kent and Medway that is rated outstanding – I want to keep the best of that, but I want to put it alongside the number of GP practices in Kent and Medway that are also outstanding and find the best way to treat the patients we need to treat.
VV: Are you working with them to build this ground-up strategy or have you got a plan to produce something at ICB level? How are you progressing that?
PB: We think the best way is from the front line. So I touched earlier on healthcare partnerships, HCPs, the geographical four. They are working up their plans for neighbourhood teams and how they would like to implement them. We don’t think it’s right for us to instruct them; we think it’s right that it comes from the front line.
VV: What do you see as the ICB’s role in terms of workforce? What is your view and approach to workforce across the system?
PB: GP practices are independent businesses – as are local pharmacists, optometrists and dentists – and it is not for the ICB to tell them what they should do. We have to work with and alongside them.
The additional roles reimbursement scheme (ARRS) roles gave us an opportunity to do that. ARRS roles, done in the right way, are game changers. But they can’t be robbing Peter to pay Paul. If each of our 42 PCNs takes a mental health practitioner, paramedic, or pharmacist from elsewhere in Kent and Medway, we destabilise a balancing act. It’s making sure that we’ve grown the overall pie rather than robbing one part of the system to pay the other.
And it strikes me that PCNs, where they are successful, sometimes bring practices together to share workforce resources that they otherwise would not be able to do if they were just operating independently.
PCNs were created to do more than the DES, and I am interested in what happens when the existing DES runs out. How do you mainstream that? Because when I talk to GP colleagues in Kent and Medway, they’re saying, ‘We’re a bit worried about our level of exposure and risk. We’ve got the funding for another year. That’s great. But how do I make sure that I will still have that paramedic after the 1st of April next year?’. The sooner that we can bring certainty to that, the better.
VV: This time next year, what would be a success for your ICB? Do you think ICBs will be in place long enough to make the intended difference to health care?
PB: As an ICB, we have two things to keep front and centre. We’ve got to make sure that we manage the now because that creates the space to manage the future. In the Kent and Medway context, the now is about too many people waiting too long to get into GP surgeries and elective theatres. And we have a particular challenge in Kent and Medway about maternity services. So we’ve got to manage what we do today so that the service provided is better than it was before. That will allow us to manage that preventative agenda. So, you know, diabetes, hypertension, some of the profound impacts of the pandemic on children and younger people, and the health inequalities. So I think we’ve got to do both – it’s sometimes a tension, but we have to do both.
I don’t believe as a public service that we have a divine right to exist. So ICBs should be here as long as they are doing things that are bettering the population’s health. Could they do that when they were one day old? No, because things take time. So if we were having this conversation this time next year, I would look for accelerated progress – a demonstrable piece of evidence that says, ‘The system in Kent and Medway is better than it was a year ago for the people that we serve.’
How we measure that, you can pick and choose off the menu – whether it’s fewer people becoming poorly because of strokes or hypertension or fewer people on an elective waiting list or an IPSOS Mori poll. However it’s measured, we’ve got to tangibly have done things that improve the health of the people we serve.
VV: Lastly, your financial position. How is it looking at the start of the new financial year?
PB: It’s really tough. I’m not unique in that. The budget last year for Kent and Medway ICS was £3.65 billion and we’ll get pretty close to that – it’ll be a bit over, but it’ll be pretty close. But there’s no doubt that this year’s planning round is really tight. We are still going through the process to make sure that we get to the numbers that make sense.
We are not unique in Kent and Medway public services with that. I speak with the local authority chief execs, the chief constable, and all the public servants are in a similar place. So, I’m not saying health is special. The issue for me is that we have to get to a balanced position as quickly as possible because while we’re having the conversation about planning, we’re not having the conversation about doing. And it’s the doing that makes the difference. The planning is important, but let’s get to the doing as quickly and as meaningfully as we can.