Rob Webster, chief executive of West Yorkshire ICB, tells Healthcare Leader editor Victoria Vaughan about how eschewing payment by results in favour of aligned incentives frees up funds for immediate investment in primary and community services.
Victoria Vaughan (VV): Can you give and overview of West Yorkshire ICB?
Rob Webster (RW): We’ve been working as a partnership in an integrated care system since 2016. The introduction of the integrated care boards as an organisation within an integrated care system has been interesting for us because we already had a very strong partnership ethos in West Yorkshire.
We’ve got 52 primary care networks (PCNs) and 10 trusts delivering mental health, community, and acute services to two and a half million people. There are councils, third-sector organisations and hundreds of practices and community pharmacies. So, we’ve got well-established organisations in our system.
The population is diverse – 20% come from different ethnicities than white British. And we’ve got people who feel a deep connection to Heptonstall, Armley, or wherever they’re from.
Deprivation significantly impacts some of our populations in West Yorkshire, which is important in setting the context. We’ve got 22% of people in the lowest decile of deprivation. The cost-of-living crisis has had a greater impact on people here. We tend to have higher levels of sickness in the economy, which means it’s more difficult to be productive and efficient.
And we’ve got financial distress like everybody else, as have our councils.
That difficult context could make you feel gloomy, but actually, we should feel hopeful. What gives me hope is the fact that we’ve been working together as a partnership consistently, making sure that unwarranted variation in care is addressed and prioritising health inequalities.
VV: What are the top three focus areas for you as ICB leader?
RW: We’ve been refreshing our strategy for the next five years, and we have a joint plan for the things we’ll prioritise.
The first one is operational delivery today – how are we supporting our partners to deliver services and allow access to services?
The second thing we’re focusing on is what we do in the short term over the winter and into next year; how are we making sure that we’ve got in view what’s coming down the track?
Then, the third thing is how we move from a position of what feels like continuous firefighting into a planned position of progress.
VV: You mentioned health inequalities earlier. I’ve just read your latest report and it talks about flat access not being fair access in terms of deprivation. How are you approaching that in terms of money?
RW: The general approach is high level and the focus is on health inequalities.
We know where we are now – you know, shocking statistics about life expectancy for people living in deprived communities and serious mental illness – and we want to reduce those inequalities.
For healthy life expectancy, we get there by building capacity, capability and insight into the things that make the biggest difference. We have a health inequalities academy that brings together experts to consider with partners in local government and the NHS what the interventions will be.
If we want to reduce demand, improve the public’s health and take account of inequalities, what do we do around prevention? For example, for a major killer like cardiovascular disease, we know that high blood pressure is one of the biggest issues. We know that a third of adults over a certain age have high blood pressure, and half of them don’t know it.
So, we’ve gone out to communities – we’ve targeted communities who tend to be underserved in primary care – and we’re doing mass testing of people’s blood pressure. We wanted to find people who are hypertensive and then to manage the hypertension within safe limits. We’re finding 20 to 30 to 40% of people in deprived communities are more likely to have high blood pressure.
That’s just an example of where we’ve got a structured and evidence-based way of thinking and then supporting it through Places and the systems to deliver what’s needed.
And, to augment that, we have communities of practice. If you’re a physician who’s interested in the public and population health evidence around stroke, or a community manager who’s also interested in this field then you can be part of a community of practice.
There are a lot of people who have a professional interest in health inequalities. We’ve got health equity fellows – a fellowship where people from the third sector, the NHS and councils give one day a week to work on a particular topic or project linked to something that drives inequality.
Next for health inequalities is to look at certain populations. We know some are going to have poorer outcomes.
VV: How are you using the Core20plus5 money in West Yorkshire?
RW: We decided to allocate half the money to Places as we have a place-based model still and we allocated that based on the proportion of people in the lowest decile of deprivation.
So that meant Airedale didn’t get any money because they’ve not got anybody in that kind of population and Bradford got more money. That’s always going to be a difficult conversation, but it wasn’t imposed on people. It was a collective decision because that’s what we do and we’ve got a fundamental agreement that we’re here to tackle inequalities.
We’ve used the other half of the money in targeted investments across West Yorkshire. So, for example, groups like homeless people, offenders and various others who face health inequalities and poor outcomes.
VV: How are you measuring the work that you’re doing? Are you able to see a difference?
RW: We have a set of lead indicators against our 10 big ambitions – and three of them are about health inequalities – which we think will demonstrate improvements in the future. You don’t get the data for a while. For example, the data on life expectancy and healthy life expectancy for learning disabilities are lagged.
But there are some things you can start to consider. Your leading indicators are things like health checks, access, satisfaction, etc, which we’re looking at, and increasingly we’re trying to ensure we use that tool on primary, secondary tertiary prevention to assess what we’re doing.
And if you look at our board assurance framework on our strategic risks, a big one is that the people’s living conditions offset any improvements we make. So, clearly, our partnerships go beyond the NHS to help with that. We have deep connections in housing, education, and the environment.
VV: Because health is just one part of the problem?
RW: Yes. The evidence around the national major conditions strategy said homes were one of the three biggest environmental factors for early mortality. So, our housing and health programmes are looking at how we can ensure that people have affordable, warm homes.
In all five of our places, local government is leading on support for citizens around the cost of living and we’re contributing to that too through our partnerships. There’s a collective set of resources for where you live and how you can access it because we know people will need that. We’ve been signposting people to benefits advice, debt advice and where you can get grants for affordable warmth.
We’ve even been connecting people to communities where there are warm spaces that aren’t called warm spaces, so people don’t feel stigma about going there.
VV: What about your Fuller board and your strategy for primary care in West Yorkshire? How are you getting people seen before they need hospital?
RW: The starting point was a need to create the conditions and have the right incentives to allow people to be seen appropriately and to focus on prevention. Before the pandemic, we introduced a financial regime of aligned incentives. We didn’t use payment by results, which the rest of the country has done.
We’ve incentivised reducing waiting lists so people can be seen and treated in the right place. We all need to work together if hospitals are going to be sustainable and if communities are going to get the right kind of deal.
And in 2019-20, we had a single control total, and all our organisations were in surplus except one. That was an improvement over the last three years. So, we’ve moved from being in a pretty bad place in 2016 to a much better place. This year, we’re the only ICB that’s been able to negotiate a different elective recovery fund arrangement. [See Box]
Alongside that financial regime, we’re thinking about clinical models. Recently, we’ve been focusing on the interface between primary and secondary care. Mid-Yorkshire hospitals, working with Kirklees and Wakefield, have a shared model of care in just about all specialities now, which goes beyond advice and guidance and into ‘How do we support this person now and what do they need?’ There’s been a substantial reduction in tests and people are now waiting a few days rather than months for the treatment required.
There’s still work to do. I could play our greatest hits and it would sound fantastic, but we’ve got some duff tracks as well. Last week, we had a big workshop where people came together to look at where we’re getting it right and where we’re not. Given that most of our trusts are integrated trusts and do community services as well, it’s all the same agenda really.
And we are trying to shift to general practices feeling sustainable. They’re just running so fast at the moment that it just doesn’t feel sustainable.
VV: What will that look like?
RW: We want to move from a focus on the primary care access recovery work into looking at a sustainable model in line with the Fuller approach. That’s where you’ve got multidisciplinary teams and people focusing on individuals with the highest needs and thinking around how a flat offer is an unfair offer – and you have the IT, the buildings, and the staff to do the work.
And actually, we’ve got a lot of the building blocks in place. When you start with the person, it becomes easy for us to consider.
In general practice, 20% of consultations are a social issue. Patients ask them to solve a social issue that manifests itself mentally or physically. Half of consultations will have a mental health component. A smaller proportion are purely physical, and a very small proportion require a second opinion.
If you look at things through the patient lens and if you’ve got a need in your community, there should be a team that is available to support that. With PCNs, we’ve got pharmacists who can help or access to counselling – we’re changing community mental health services, so they’re linked directly to PCNs – and social prescribing and wrap-around support from the third sector. We’ve got a proxy family and we’re looking at the whole person.
But we need practices to work together with partners to create that multidisciplinary team. And we need more of a strategy around what the estate and the data then look like. You can’t have integrated services without integrated data and workforce. There are bits of West Yorkshire where there are amazing examples of that, but not everywhere. We need a national set of arrangements which support the creation of that everywhere.
VV: What do you think that national set of arrangements will be?
RW: It starts with an ambition and a vision for what it looks like. I think Fuller starts to paint a picture of that. We then need to recognise that it’s a core part of what we do as integrated care systems.
With integrated care systems, the clue’s in the title – it’s joined-up care. People are captains of themselves most of the time, without any bother from us, but sometimes they need a bit more support. And sometimes they need a lot more.
A practice can’t do everything; you need some things at scale. So, you can’t do everything in Armley, you might have to do it at a Leeds level. And if it’s not in Leeds, then it’s West Yorkshire. We need some kind of infrastructure to support working at that level and that’s the bit that really needs a bit of thought.
VV: There’s nothing nationally that prescribes how it should be done. And so, while there needs to be this integrated neighbourhood team – the Fuller idea of a wider PCN – it’s still not clear on how that happens. So, locally, will you figure that out or do you need to wait for something more from the centre?
RW: No, we don’t need to wait. We’re sick of waiting. And you can’t decide how primary care works in Batley from Whitehall.
We need to find out how we continue to get people to want to work as partners in general practice as part of a broader primary care network within a place.
And in doing that, as leaders in local places, we need to be comfortable with the fact that the way it works can vary because populations vary. It won’t be that we’re telling people what to do. We don’t want primary care to be managed; it’s not a directly managed part of the system. We’ll be incentivising the right things to happen.
In West Yorkshire, some places are well set up. In Wakefield, we’ve got the team from Conexus, the GP federation. All the leaders of the local general practice sit on the Place committee in Wakefield. Practices are strong and responsive and they’re pushing on what integrated teams look like in our places.
The other four places have got different models and they’re at varying degrees of maturity. So, we’ve got to share best practice and think about the things we will insist have to be in place because I think you need some infrastructure in a neighbourhood to deliver that joined-up working – connecting primary care with communities and acutes. Then, their players-based arrangements can differ.
In Leeds, the GP federation has a set of joint posts with the community trust – joint nurse director and medical director and so on – so that there could be an infrastructure to help foster what goes on across Leeds.
VV: You mentioned incentives. What kind of incentives are you looking at to get people to kind of operate at this level?
RW: At the highest level, the aligned incentive contracts are saying to the hospitals, this is the money that you’ve got, and we’ll count how much activity you’re doing and what the case mix looks like and so on. If we don’t manage it within a reasonable tolerance then we lower your money and if you don’t do enough, you’ll owe us money.
It means you can invest in primary and community services straightaway. It’s different from payment by results – then you can’t invest money because you might need it to pay the bill later. But this way, you’ve paid the bill upfront and you’re clear about the risk and you manage that between you across the year. And you’re all being open about that.
That gives you some money to put into incentives – some of those are national and some are local.
There’s scope in the future to say: ‘OK, what do we want to incentivise?’ We could think about some kind of local incentive on the outcomes that we want to see.
VV: Finally, where do you want to be at this time next year?
RW: This next year is going to be really difficult. We’re in a period of transition. Though, it’s feeling better than this time last year. Things are pressured, but we have a good set of arrangements with our partners and colleagues.
I’d like to get through the winter in a way in which people stay with us, and by this time next year, I’d like to be focusing on the medium term.
Right now, we’re focusing on the short term all the time, and we need to focus on the medium term – answering these questions around how to have viable and sustainable primary care, which brings together the best of pharmacy, general practice, dentistry, optometry, community services, and the third sector.
I’d like people to start seeing the progress rather than thinking about survival or recovery. And I’d like everybody in the system to understand that this is the best way to work.