Zina Etheridge, chief executive of North East London ICB, talks to Healthcare Leader editor Victoria Vaughan about work to attract and retain GPs in outer London when it competes with nearby services offering salaries with an inner-London weighting.
Victoria Vaughan (VV): What are the unique characteristics of the North East London ICB area?
Zina Etheridge (ZE): There are three particularly notable things – it’s fast-growing, diverse, and young.
Our area has grown by about half a million people over the last 20 years and we expect it to grow by another third of a million people – that’s the size of a large London borough – by 2041.
It’s really diverse – 53% of our residents are from black, Asian and mixed ethnicity backgrounds compared with 11% across England overall. There is a lot of deprivation and also massive variation. We’ve got the City of London, which is, of course, the financial capital, and Canary Wharf right through to Barking and Dagenham, which is one of the poorest boroughs in the country.
And we’ve got the highest birth rate in the UK. So, we have quite a young population with loads of challenges around that, but no ageing population.
VV: What are the top three things that you’re focused on in North East London ICB?
ZE: The first is financial sustainability. That’s everything from overcoming the budget challenges in the shorter term to working through what resource allocation would look like if we did it on a population health basis.
The second is population health and how we tackle health inequalities, particularly given our deprived population and the inequalities that our populations face.
And, lastly, it’s the demands of delivering services today, particularly urgent and emergency care, which has been really pressured in North East London. Outer North East London was in the NHS’s tier one for urgent and emergency care systems, which is the worst tier, but we’ve come out of it into tier two and we’re the only system that’s done that. So that will carry on being a real focus for us.
VV: What did your system do to get out of tier one into tier two?
ZE: It reflects a whole system effort on urgent emergency care in outer North East London.
The hospitals’ performance has got better because of concentrated, ongoing leadership. Barking, Havering and Redbridge University (BHRU) Hospitals NHS Trust covers King George Hospital and Queen’s Hospital and they have been working hard to get better at flow and all sorts of other things. It’s a long really hard grind – top down and bottom up – change process.
There has also been effort to ensure the urgent treatment centres (UTC) – the provider is the Partnership of East London Co-operatives (PELC) – has the right skill mix and the right governance in place so the pathways between the hospitals and the UTCs are working properly.
Then there is the wider system working. For instance, there’s been work on frailty pathways between the hospital community services provider and local authorities. There’s a focus on getting people out of hospital sustainably. One of our local authorities has moved part of its reablement team to working with people on the hospital wards so that, hopefully, they’re able to go home rather than having to go into a care home, which causes delays.
And there’s been a focus in our wider partnership on admissions avoidance, so there are fewer people going into hospital in the first place.
VV: I understand North East London ICB has a higher attrition rate than the number of GPs coming through. What are you focusing on in terms of your primary care workforce and what are your areas of concern?
ZE: This is no different to most other parts of the country. We’ve got an ageing workforce – around a third of our GPs and practice nurses are 55 plus – and we’ve got fewer young GPs coming through, so there’s a net reduction in numbers.
We also have a dynamic in London with inner London versus outer London weighting. It’s easier to keep people in central London than it is in outer London across both hospitals and general practice.
We’ve been looking at different ways to attract and keep our GPs. We have been working on our own scheme which we call SPIN – salaried portfolio innovation scheme. It’s focused on enabling GPs to do academic work, as well as being in practice. It offers portfolio roles to GPs and other professionals so they can work in specialist placements and leadership roles. As pilots, we’ve expanded those to mid-career GPs as well as clinical pharmacists.
And we’ve got an aspiring partners programme, which offers development opportunities to GPs and nurses. We have put in place other training programmes and mentorship, and we’ve been focusing a lot on making sure that GPs are able to recruit to the ARRS roles.
I know there are some oddities in the scheme, which GPs tell me make it particularly difficult, such as an ARRS role doesn’t always get covered if there has been an existing role. But we are absolutely supporting them to use those roles as fully as possible. We’ve recruited more than 1,000 FTE additional roles to work in PCNs since 2018.
VV: You mentioned a move towards funding on a population health basis. How are you approaching that?
ZE: We’re focused on trying to understand where our health inequalities are. So, for instance, our acute providers looked at waiting lists to identify some of the greatest inequalities and found they were around dentistry and people with learning disabilities. So, there are specific measures in place to really focus on and tackle that inequality.
VV: What’s the ICB’s role in supporting general practice?
ZE: It’s really important. We’ve got a primary care collaborative, which is focused only on primary care. The reason for that is because otherwise my worry is that primary care gets lost in amongst everything else.
As we’ve moved into being the ICB, our teams work really hard to support primary care and to understand where practices need support. We’re doing loads of work with practices on all the telephony stuff and primary care access.
I spent a bit of time earlier today with the GP IT team who were flashing up their satisfaction statistics. And they get really high rates of satisfaction from practices. It’s a bit of infrastructure that people don’t often think about, but actually making sure that GPs have got the right IT support is quite important in enabling them to do what they need to do.
And we also have to blow the trumpet for North East London, who have the highest uptake rate in London for the new Pharmacy First scheme. That’s because it builds on the community pharmacy consultation service, which we have the highest referral rate for in England.
VV: In terms of primary care access, you’ll know that North West London is considering splitting same-day care from other care. What’s your take on that and is it something you’ll do?
ZE: I won’t comment directly on North West London’s model, but the conversations I have with primary care practitioners are about ensuring people can get the continuity of care that they want.
We’ve just done work in which we talked to about 2,000 residents in various different ways. And they told us that it wasn’t just about access but it was about trust in the process. So, they might get a very quick response, but if it wasn’t from somebody that they trusted, they just went to ED anyway, or they phoned 111.
Some of our practices are doing the most extraordinary things and thinking about how they can triage most effectively. We’ve got some phenomenal rates for same-day access, which is partly down to some really interesting innovative triage models.
I went to see a practice two weeks ago and they’ve gone from a situation where they had no chance of getting through everybody who phoned at eight o’clock to something quite different. On the day that I visited, I went up to the receptionist about three o’clock and a patient could have phoned then and had an appointment on the same day. Now, that wouldn’t necessarily be with the GP – it might have been with a nurse practitioner, advanced nurse practitioner or a pharmacist – but the point is that there’s some really great stuff going on.
GPs can be really entrepreneurial. We have to make sure that we continue to support GPs in models that enable them to be hyper-entrepreneurial, flexible and responsive in how they provide their services.
Those are the conversations we’re having – what are the best models for doing that and what works for us locally?
VV: How would you rate your engagement with primary care?
ZE: There’s always going to be room to improve so I am not going to say we’ve got it cracked. We have the primary care collaborative, as I said, and our primary care team does a lot of day-to-day engagement with primary care. We’ve got two primary care members on our board, and different committees.
We’ve appointed a clinical leader in each of our places and, coincidentally, they are all GPs, so we hear quite a lot of the GP voice through that, and there’s engagement with the LMCs.
The next stage for us is to make sure that the primary care voice is coming through strongly in our place-based governance and partnership working.
VV: Do you have integrated neighbourhood teams in North East London?
ZE: We’ve got seven Places, and integrated neighbourhood teams are very different in each of them.
In City and Hackney, integrated neighbourhood teams are quite mature. And in other places, they’re a long way behind.
There’s an opportunity to learn really fast from what’s happened elsewhere, but obviously it needs to work with what’s there locally and how people are working together. And we’re having quite interesting conversations about it.
VV: So, do you feel that those integrated neighbourhood teams will come up from the grassroots? That they’ll emerge and develop in a way that suits the local area?
ZE: I think it has to come from the local area because the whole landscape is really different in our Places. I don’t want to impose a model on it because that doesn’t really work with what’s there locally. So it’s got to it’s got to come up from the local area, but it’s a bit more than just letting it emerge.
Obviously, integration over the tiers is a really important part of Fuller, and therefore, it’s a really important part of our overall programme management. So, it’s a really strong focus for us and it’s supporting Places to develop integrated neighbourhood teams in a way that works for them and meets the needs of those residents.
VV: You talked about finances being one of your priorities. What is North East London ICB’s current financial position?
ZE: We have the lowest capital allocation in London, despite having a really big chunk of the population. So, our capital is really stretched. We have been developing the information data and modeling to demonstrate what happens when you put our increasing population on top of an already low capital allocation. So, winning the argument for more capital is one of our financial strands.
We said in September that we’re projecting a year-end deficit of £25 million. Obviously, industrial action makes everything a bit more uncertain. And there is a substantial underlying deficit, which we need to tackle over the longer term to be more financially sustainable.
And, obviously, authorities are also hugely financially stretched. So, it’s pretty challenging. I don’t think it’s significantly out of line with that of a lot of other places, though.
VV: Where do you hope to be this time next year?
ZE: I would like a much stronger financial sustainability and to start seeing some successes from our integrated neighbourhood teams everywhere.
I’d like to see population health starting to influence the way that we manage our programmes and our resources.
And I’d like to see us making further progress with tackling some of our health inequalities.
