As the only NHS ICB leader from the third sector, Tracey Bleakley brings a fresh perspective. She previously headed up Hospice UK and is now chief executive of NHS Norfolk and Waveney, where the challenges are plentiful. It spans a rural population where some people can live a long way from health services, and it has fewer beds for its population than the rest of the country. So, unsurprisingly, the winter pressures hit hard. Here, Tracey Bleakley 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 Norfolk and Waveney?
Tracey Bleakley: We cover an ageing population with one in four people over the age of 65. There are pockets of affluence and real poverty. Norwich, King’s Lynn and Great Yarmouth are our more populated places and we’ve got three acute hospitals which work within those patches.
We also have a big farming community and a dearth of public transport, so we have people who live quite a long way away from health services.
Within our pockets of affluence – such as North Norfolk, which is where people go to retire – we have little pockets of poverty that we don’t necessarily see. We are predominately white British, but we do have different ethnic groups. And we can be quite seasonal – we have a lot of tourists and seasonal workers who swell our numbers in the summer and then disappear in the winter.
Alongside our three Trusts, we’ve got two community trusts. One is Norfolk Community Health and Care NHS Trust, and that’s part of the NHS. And we have a social enterprise, East Coast Community Healthcare (ECCH) which has the community contract for Great Yarmouth and Waveney.
We share a mental health trust with Suffolk so that’s Norfolk and Suffolk NHS Foundation Trust (NSFT). There are 105 GP surgeries and about 400 care homes. Like everywhere else, care homes are closing down or being rated as inadequate by CQC, so we have real issues around social care provision. In particular, domiciliary care is difficult.
We are underbedded per head of population compared to the rest of the country and that’s really hit us this winter. When you have winter pressures, it affects the flow through the system in a colossal way. Obviously, with the winter money, we’ve been buying more beds on a temporary basis.
We also have far fewer side rooms per head of population than most other systems. That’s really tough when there’s an infection control issue. So this winter’s combination of two different strains of flu, Covid, Strep-A and Norovirus, really hit us hard, especially with an aged population. That led to a lot of ambulance delays over Christmas and New Year.
VV: When you say you’re buying extra care beds, where are you buying those from?
TB: It’s a combination. Like the rest of the country, we are going to social care providers to buy additional beds. We’re also opening up facilities that had been closed and mothballed, such as community centres or even wards within our acute providers. Our two district general hospitals in Great Yarmouth and King’s Lynn are falling down. They have RAAC plank issues. In Great Yarmouth, we safely reopened a ward that was due to undergo work to create more beds. Like other places, we’ve also opened a lot of virtual ward beds. So we monitored people through remote technology and then provided wrap-around care from the acute and community trusts.
VV: What are your top three areas of focus at the moment?
TB: I could talk about urgent and emergency care (UEC) or system finances, but I’d rather talk about the groups and the transformation we want to do.
The first one, which we’ve already made a start on, is mental health transformation. When I came in, straight away, the CQC report on NSFT showed that we had big problems with our mental health trust. But I also felt that NSFT was a proxy for mental illness of our services in Norfolk and Waveney, and that shouldn’t be the case. We were treating mental health as though it was an acute crisis for somebody, whereas actually, these are long-term chronic conditions in many cases. So we should treat them as we would physical health – not just constantly focused on discharging them from services. So we decided, straight away, to make this a priority.
We should have touchpoints across the whole system, and we should be working to keep people well and to direct them to the right service wherever they might be in the pathway. And really, NSFT should be about crisis intervention and acute.
So, we have set up a mental health collaborative for adults and a separate one for children and young people. Focusing on the two separately was a very deliberate decision. We are still discussing what to do about 18-25-year-olds because they’re a very specific cohort as well.
The collaboratives will look at pathways from schools and employers. They’ll also pull in some of those wider determinants of health, looking at social housing. From a health perspective, they’ll look at the support from and through primary care and other services.
They will ask the important questions. Who’s providing the services, how do we evaluate them, how do we mitigate the demand, and how do we reduce our backlogs? We work very closely with the mental health campaign group in Norfolk and Waveney, which comprises parents and friends of people affected.
Older people services is another big one. If you walked into any of our emergency rooms over Christmas, you’d have seen that they were packed with older people who were very ill but didn’t necessarily need to be in an acute hospital, which is not a good place for them to be. We blue light people in with urinary tract infections, and then they go into hospital where they de-condition. We test them for multiple things simultaneously, and they may not be drinking enough water because they don’t know if someone will help them to the toilet. They might not be eating properly because their false teeth have been lost. They get hospital delirium, and then they end up in a situation where they can’t be discharged with the same level of independence they had before. And that impacts on the length and quality of their remaining life.
Instead of admitting older people to hospital, I want to look at why can’t we dispense intravenous antibiotics in the community. If somebody needs to be monitored, then we need more community beds, or we can take beds in care homes. We could work much more closely with care homes.
If you’ve been lying on the floor for six hours because you’ve had a fall and your relatives couldn’t get you up, you are blue-lighted to hospital. The theory is that you may not have had a drink, and your kidneys might be starting to shut down through dehydration, so you need all the checks. But what if your family has been there and, although they couldn’t get you back into bed, they’ve put a duvet around you, pillows behind you, and you’ve been eating and drinking and watching TV together? We shouldn’t be conveying those people to hospital.
I want to avoid people going to hospital when they don’t need to. I want to bring care closer to home so that people can still have their care networks and communities wrapped around them. I want to support people to stay living independently for longer, and also I want to think more proactively about older people.
We shy away from having conversations with people about what to expect. But if we tell people what to expect, they could plan for it. At the moment, it’s very much as something happens – it feels like it’s out of the blue. Everyone is in A&E, completely panicking and making decisions in a crisis.
We never tell people with COPD what to expect, what we can help them avoid, or how they can live well. It’s the same with heart failure and the same with frailty. We need to talk to people more openly so they can plan.
The third priority is children and young people within our system. A lot of that is around mental health but critical health as well. A long-term investment in our young people will probably take 20 years to pay off but will absolutely be worth it.
VV: What do you want from primary care around those three priorities?
TB: Colleagues in primary care have been frustrated that they can’t refer to the right services. Or, when they do refer, it takes six months for somebody to be processed to be told they don’t meet the criteria for this service, and they’ll be sent back to the GP. GPs are frustrated because they have these patients bouncing back, and nobody will help them. So we’re working with primary care to determine the wrap-around services we can give the people they see. That’s about the Fuller review, isn’t it? It’s wrapping community services around GP surgeries and working with our PCNs.
VV: Do you have anything like that in place? Have you got integrated neighbourhood teams in your patch around mental health?
TB: We’re starting that, yes. Everyone said that services around dementia were needed, and, of course, this ties in with older people. So we’ll be piloting that over the next 12 months. The collaboratives don’t become real until April 1, so we’re in the foothills of having those initial meetings and people agreeing on what they want to do.
VV: Where are you at tackling health inequalities in your area?
TB: It’s the golden thread by which we should think about everything.
We were really innovative in Norfolk and Waveney on population health management through the pandemic. That was before my time here so I can give the system real credit. We had Covid Protect, which looked at the most vulnerable people in our community and ensured they had the wraparound care they needed. It linked with the local authority, making sure people had their shopping and their health visits.
We’ve expanded that system and called it Protect Now. It’s looking at different conditions and vulnerabilities in our society – that is, the people who aren’t necessarily going to come to us.
We know that with a lot of our population, it tends to be the white middle-class people who will present. It’s different for somebody who feels the health sector has looked down on them all their lives and is potentially in a zero-hours contract and working all the hours God sends to pay the fuel bill. That person isn’t necessarily going to present early when they’ve got a health problem. So we’re looking at different conditions and markers to reach out to people and say, for example: ‘We need to do a diabetes check. We can see how long it is since you’ve been in, and we think we can help you avoid some future issues.’
VV: How are you getting that message out there to those communities?
TB: It’s direct. It’s on a patient-by-patient basis. We’re contacting the patients directly and saying, ‘We’re offering you this. We’d like you to come in because you flagged up on our system that this will be quite useful for you.’
We’ve also discovered that our local authority has masses of public health data that wasn’t available to us. We are starting to look at joint teams between ourselves and the local authority, so we have access to that data. Then we can share resources and have a much bigger evidence base in terms of where we’re going to prioritise. It’s going to be really tough financially for the next few years. We need to be led by the evidence to see how to make the biggest impact.
VV: So that’s informing your priorities already?
TB: It is. Work is going on in all areas of the system, and there are so many people with small projects. The PCNs are so innovative. We’re making sure they have the data and linking them with the district councils and county council to talk about things that affect the people they’re looking after. Things like debt advice or housing can make a massive difference to people’s mental and physical health.
We’re trying to ensure that our primary care partners know what grants are available from the district councils and where they are. That way, they can start making a big difference to some of the people coming in who can’t afford to feed themselves or can’t afford to pay their energy bills, and so they get ill. There’s money available, so we’re connecting that up.
VV: What is your opinion of primary care in your area at the moment? How are you working with them? How resilient is that sector?
TB: I look at the stats, and I can’t believe how much they’re doing. In November, we had 690,000 appointments – and that’s in a population of 1.1 million. It’s unbelievable. And we’ve got 45% of appointments on the same or the following day. So what they’re doing is phenomenal.
We are also at a higher-than-average percentage of face-to-face appointments. And our patient satisfaction survey results are higher than the national average. We have pockets where we’re working with practices to improve, but in general, they’re doing an amazing job.
I am nervous about their resilience due to the number of GPs who are coming up to retirement because we’re not seeing doctors who want to buy into a partnership coming through. We know we’ve got to deal with that. We know we will see increasing numbers of practices that will not continue in the partnership model. So, we’re talking about what will happen when GP partners retire and hand practices back. We’re looking at various alternatives to the partnership model.
VV: Why do you think that is? If something could change to help that, what would it be?
TB: I’ve never worked in primary care and only worked in the NHS for a year. Before this, I worked in the third sector and was the Chief Executive of Hospice UK. So my perception needs to be seen in that context.
Being a GP is still a rewarding profession, and it can give people the flexibility they want to pursue other avenues, such as research, portfolio careers or part-time work. The big problem is why would somebody want to come in and run a business as well? Because, actually, they’re getting knocked for it as though they’re somehow squirrelling money away from the NHS and it’s some sort of private venture. And I don’t think the media helps.
If I was a young doctor going into general practice, I’m not sure I’d think, ‘Oh, and I want my practice one day.’ The potential liability, all the HR, what happens if you can’t hire people – it’s all on you, isn’t it? Running a business requires a lot of time, effort, worry, and stress. Whereas you can just come in as a salaried GP, do your shift and go home.
VV: In terms of your PCNs, you said that they’re innovative, is there anything that you can pick out or anything that you’re wanting from your PCNs to support the system and where you’re heading?
TB: One of the things that we’re trying to do is pull back pathways from the acute hospital. Much of that is around earlier diagnosis or more support in general practice and communities, so people don’t have to go to the acute sector. And, even if they do, can we do things through telemedicine? For example, we trialled that in dermatology, and it’s started to work well. We can diagnose people earlier, we can signpost people much more quickly if it’s potential skin cancer and get them through the service.
Also, we’ve got an MSK partnership here and we’re allowing people to self-refer. I think the leader of the opposition was saying the other day that people should be able to self-refer to physio – they can here. We have a portal that people can visit for information on their condition, self-help and how they can self-refer. I want to do an awful lot more of that – people shouldn’t have to go through primary care if it’s not adding any value.
VV: In terms of the Fuller stocktake, how will it impact primary care in your area?
TB: I was one of the chairs in the Fuller review – for older people and death and dying – so I was very much prepared for what was coming out. We’re doing a lot around the integrated care teams in the East. We’re talking about how we copy that and how we move that around. That will be absolutely key to our older people’s service and mental health. We’re using the Fuller review as a framework for building the services to give us the transformation we need. But for me, it’s all about those integrated teams and multi-disciplinary teams, and we need to wrap around and support primary care. It just makes absolute sense.
VV: What is the financial outlook like for your ICB?
TB: We have an underlying financial deficit. Obviously, it’s been different through Covid. Last year, we made a surplus and, this year, we are still reporting a break-even position – but it’s very tough. I think it’s going to get increasingly difficult to do the things we want to do across the system. We’re starting our negotiations for next year already.
The sad thing is that there are so many ideas for investment, and actually, we’re having to say we just don’t have a lot of money. But I never want to say no to anything because we don’t have the money, so it’s about thinking, ‘How could we do that? How could we triangulate it?’
The financial side of things is always going to be tricky. The best thing would be the longer-term surety about money. When you get a pot of money, and you’re told you have to spend it by tomorrow, you don’t spend it on the right things, do you?
VV: What’s the workforce outlook like in your ICB area?
TB: I think everyone’s really tired. I think people are burnt out. This isn’t fatigue from one year; it’s three years. We’ve got quite a demoralised workforce in certain areas. It’s a general sense that the public doesn’t care about health workers in the way that they did at the beginning of the pandemic.
And this is where the strikes come from. We’re trying to support both sides – our striking colleagues and also those who aren’t striking. But being in a situation where we have industrial disputes isn’t going to help in terms of having a happy or motivated workforce.
We’re trying to look at longer-term retention. We’ve got various programmes ongoing in terms of recruitment, but I am worried about the number of people talking about leaving the health service. It is a really tricky time. But then again, it’s a tricky time in education as well. It’s a tricky time in so many industries, isn’t it?
VV: Are you planning for your future workforce? Have you identified things that you can do in your patch to bolster the workforce?
TB: We’re looking at things like career passports so that people can work across health and social care in our area. Our people director only joined us in November and she’s pulling together our strategy at the moment.
So, there will be more to talk about in the next couple of months. Workforce is a real issue for us, as it is for many others. We’re also trying to attract people to come and live in Norfolk and Waveney. That’s GPs, dentists, consultants, nurses and HCAs – right across the board, we need to convince people to come and work in this beautiful place.
VV: Where do you hope to be this time next year?
TB: Well, we’ve just come out of a critical incident after four months, so it’s been a very difficult winter. I’m hoping, next year, I can say to colleagues: ‘My goodness, don’t things feel different in acute and primary care in terms of urgency and emergency care this winter?’
I also hope I won’t see data from our ambulance service saying we have let people down. And I’d like to see that patient safety and the quality of care have improved across our system.
I’m hoping we can see an improved staff survey as well and that we all start to feel like we’ve turned a corner. It would be great if people felt proud that they work for health and social care in Norfolk and Waveney, that it’s where they want to be and where they see a long-term career.
Urgent and emergency care is the first area our plans will impact because, this winter, we’ve had that perfect storm, and everything hit. We’ve had mental health referrals and people sitting in EDs for days and days when they shouldn’t be there. We’ve had EDs packed full of frail old people who are very ill.
We started planning for next winter in Easter 2022, so let’s hope that the things we’ve put in place will start to make an impact by the end of this year. I want people to get care where they need it and get better care due to a less stressed system. But we’ll see.