Covering 950,000 people, NHS Coventry and Warwickshire is one of the smaller ICBs. But its patient-body is diverse, compounded by a semi-transient student population across two universities. Chief executive Phil Johns discusses the ICB’s current position and his hopes for tackling inequalities.
Jess Hacker What are the unique characteristics of Coventry and Warwickshire?
Phil Johns In Coventry and Warwickshire, we’re benefiting from the work that has gone on before the ICB. We’ve got very strong relationships with both of our local authorities, with quite a history of working at place level. Coventry is a Marmot city [a network of local authorities developing an approach to tacking health inequalities based on the work of Professor Sir Michael Marmot], and Warwickshire has three quite distinct places within it. And we’ve got strong general practice and strong providers, so that gives an incoming ICB – as a partnership vehicle – really strong grounding to work from.
Population-wise, it’s a real mix. Some areas have quite severe deprivation, particularly in Coventry, but the there are some very affluent areas, particularly in the south. That’s the case for most areas, but what makes us unique is we don’t have the extremes of rurality that most other systems are faced with.
JH What’s an area of hyperfocus for your ICB?
PJ We’re taking the Core20PLUS5 forward: we’re already working on that in Coventry but we need to build on it. There will be a focus on our more deprived areas, but it’s sadly been lacking from health in previous years. That’s one of the exciting parts of being an ICB: that explicit purpose trying to tackle health inequalities. We’ve talked about it for years in health, but it’s never been such a core purpose in any of the predecessor organisations. It’s not a Coventry-only problem for us – we’ll have to prioritise resource down to those areas in Coventry, but also in parts of Warwickshire too.
Quite how we do that we’re still working out, but I imagine it will be through differential investment into primary care network (PCN) areas and those communities – so general practice, the voluntary sector and community services. We have to recognise it’s appropriate to invest differentially across Coventry and Warwickshire.
JH So what’s your key strategy for tackling those health inequalities?
PJ Developing our population health management right now underpins our work on health inequalities. Over the next few years we’ll have a common electronic patient record across our acute hospitals, which should be end-to-end, so GPs should also be able to add data to the system. We need to understand our local population, and engage a little more fully with the communities that we don’t reach than we have so far. We need to get away from that view of the problem lying with the community, rather than the service.
There’s not a quick fix, but it we can get to a place where our mental health, diabetes and heart failure services are easier to access, then we can start to change that curve.
And we’re just one part of that. With ICBs, there’s also the local authority which is well positioned for helping with employment: one of the biggest factors in health outcomes. To really shift that curve we need to anchor alliance work that local authorities lead on – working with big health providers and universities – is key. We’re keen to protect investment in in Coventry and Warwickshire, building from the additional funding for health inequalities that came through this year.
JH You’ve mentioned mental health services, which are experiencing extreme demand nationally. Is a change in direction needed to get on top of that locally?
PJ We’ve got to refresh our mental health strategies this year and we’re keen for that to focus on wellbeing too, rather than acute psychoses or similar, so we need to broaden our offer.
Mental health services, despite working really hard, aren’t able to keep up with demand, so waiting times are longer than we would like. Many people using mental health services present with a range of other issues. They might need support with long term condition management, or advice for other factors affecting mental health like debt or finances. That’s where our population health approach comes in: we need to identify the range of conditions that people are presenting with and try to guide them through our services better. One of the great things about the social prescriber role has been helping those patients navigate services, knowing where to send them; we’ve gotten very good at signposting but that can mean those services start to feel the strain, particularly with the impact of cost-of-living.
We’re not where we need to be on mental health at the moment. The investment helps, but it’s getting bodies on the ground that is proving to be difficult. taking that person-centred approach to presentations, and assessing actual need rather than shoehorning them onto a pathway, will hopefully take some demand off staff working in adult and children’s services. We have to look at what we can realistically achieve in terms of the workforce we’re able to attract towards mental health going forward.
That said, Coventry and Warwickshire Partnership Trust is doing a great job embedding mental health roles into PCNs.
JH Scaling out, what are your top three focus points?
PJ Lets be candid: if you look at where we’re at [nationally], just getting through winter is a big focus for the ICB. We’re working with partners, and particularly with local authority colleagues, to see what we may be able to do to support cost of living. We’re trying to work quickly through the winter so a definite focus is keeping services safe as we do that.
Like everywhere else, we’re trying to recover services after the peak pandemic period. We’re doing pretty well with our elective waiting times, but that’s not without challenge as we’ve got to support systems that lead to elective referrals. We’re trying to re-establish anticipatory care, which our GPs and community services carry out very well – and we’re trying not to exacerbate the inequality there as we do that. It’s about recovering in a way that doesn’t worsen those inequalities.
And then there’s workforce issues related to inequality. There are gaps in the workforce and we’ve got to try and support local people into health roles. On that point, we’re working with the Prince’s Trust, local universities and the like to encourage and promote these careers. It’s all part of that view that people from our local communities are able to help improve access to those services.
JH A common claim is that the NHS can’t compete with big employers like supermarket chains.. Looking over the coming 12 months, will recruitment be harder?
PJ We haven’t seen it get harder in health, but the wider partnership of course includes social care which is famously a huge challenge. As you say, if you can get paid the same at local supermarkets for a job that might be less demanding or messy than domiciliary or home care – That is becoming challenging, to a greater extent than with health – perhaps we might see a similar trend among health roles at a level like healthcare support workers.
But of course we don’t know what the impact of inflation will be on local business, and it may be that the market for health is more favourable.
JH What’s your relationship with general practice?
PJ We’re lucky in terms of the quality of general practice: there’s only small pockets of less effective care when we look at the numbers. But it’s still being lambasted by the public who are frustrated about access, and sometimes by local councillors representing their constituents. But for the most part we can’t fault the effort, it’s just that it is difficult to meet the demand.
What we’ve been trying to do is get to a point where general practice in particular takes a seat as an equal partner with the statutory organisation on the ICB, where it can become more involved in our planning. Because, of course, with CCGs gone that very easy route to representation has disappeared with it. We’ve not filled that hole yet, but our GPs have come together as group – so PCN clinical directors, GP leaders, those in the LMC – and they’ve set out what they think the direction for general practice needs to be. That’s given us a good way to engage with them and it gives them a way to talk to us. We need to get them involved in our other decision-making across Coventry and Warwickshire.
At practice level, going forward we need to do more with the resources we have. The additional roles reimbursement scheme (ARRS), for example, has done well at bringing extra bodies into general practice (whatever GPs think of the mechanism), and the question now is how to we get community nursing and health visiting lined up around local communities, as opposed to being referred between services. We need to get better at making sure that general practice knows of all the other services that sit in the area so that it can access and use them. It’s about taking out some of that duplication patients will see. That’s not the answer by itself, but it’s a start.
I’m a big advocate for PCNs – I know there’s a mixed reception among GPs – and I think they have to be the basis of our planning. That’s a view shared by our local provider colleagues. Place-based working is good but you’ve got to get past place-based and among smaller populations to be able to make a difference.
Key to that is lining up our data resources so our PCNs have easier access to the information they need to make decision. That includes making clearer the total investment into a PCN’s geography beyond what they see go into general practice: they need to have some oversight of how patients are being managed across their patch.
JH Is there a conflict on the Board there, between general practice and local councillors representing patient concerns?
PJ It’s part of the job. Councillors quite rightly raise issues that are held by their constituents, but I’ve been relatively clear that – for the most part – practices really are working hard to be able to meet demand. In Coventry and Warwickshire, around nine-in-10 appointments are within two weeks of booking, which is better than most areas. But we can’t create GPs out of nowhere to expand the workforce, and neither can GP colleagues. We’re trying to encourage mid-career and late career GPs to stay in the profession, and councillor colleagues are reasonable: they understand what we are trying to do. We are sharing the work we are doing across the system to expand the workforce, while recognising that despite those efforts, public perception on the ground is that they can’t get an appointment when they feel they need it. It’s not easy.
JH How would you rate your engagement with primary care?
PJ It’s not where it was in our CCG days. I’ve been here two years, so I was around for the last two years of CCGs, and I’d worked in a different CCG before that. And I don’t think we’ve got quite the same practice level engagement we had before. Working with that group of PCN CDs, LMC and GP representatives gives us a really good way to still connect with general practice – it’s more that we haven’t got the embedded kind of GP engagement that we were used to with lots of GPs on the board. It’s because the context is changing. The question for us now is how does general practice want to move forward, what does it see as its own role in the system and how do we help them develop that role?
We’ll never get to a point where a hundred practices all think the same thing, but if we can get a clear view on where general practice should sit in the system – building on the Fuller Stocktake – and if we can get partners to a point where they agree that’s the best direction for the population, engagement becomes easier.
For example, as we continue to develop a common digital offer that involved GPs, hopefully some of those people who still feel bereft with CCGs exiting will see there is a clear voice for general practice.
JH How big is the ICB deficit, and how are you planning to tackle it?
PJ The system as a whole has deficit. The ICB part of that system is in balance, but my job is to manage the system rather than the commissioning budgets. The deficit is forecast to be around £5 million by the end of the year, but on £1.8 billion. We’re working with system colleagues to try and address that gap this year, even if some of those solutions are non-recurrent, potentially taking a different path around the investment that’s left this year: but really trying to work on how we establish securer financial footing going forward.
We’re looking particularly at the work led out of Coventry on older people and their experience of our care system. Of course, there’s a huge amount of resource that goes into managing that experience where it doesn’t through as it should. That should help us contain cost and fits into the Getting It Right First Time (GIRFT) programme.
And then there’s good work being done on how we pursue some of the digital solutions. These don’t necessarily take cost out but they might provide better value for money, lower cost alternative to some of the more resource- or staff-intensive solutions we currently have.
That’s not to say it’s not challenging or stretched, because it is.
JH What do the next 12 months look like?
PJ The key role for ICBs is two-fold. Firstly, we need to maintain that partnership approach we saw develop through the pandemic period: it’s really important we don’t get seen as the next strategic health authority (SHA), primary care trust (PCT), CCG. We have to remain as a partnership of organisations in Coventry and Warwickshire with an established collective plan.
Beyond that as an ICB, we have to get to a point where decisions are made closer to organisations, to patients, to professionals. Our two-year plan is to devolve our resources into Coventry and Warwickshire to encourage them to take those decisions closer to the populations they know more about. Most of my resource is tied up in big statutory organisations, so why not use that to engender better place-based working?
And the key part for us as a Board is in making sure those decisions consider the impact of inequality. It’s not just around hitting those performance targets – of course, those are important – but if we can make a clear impact on people who currently don’t access care it will help with meeting target. I’d like to be able to give away some of our responsibility as an ICB to places in Coventry and Warwickshire, so they can make decisions about how resources are deployed at a more local level. And doing that sits within the context of asking: ‘Okay, what are we doing for those communities we haven’t served so well over the last few years.’