NHS Somerset is a ‘neat’ system in the South West of England where the ICB covers the county, the county and district councils are about to become a unitary authority and the two hospitals are set to merge. Chief executive Jonathan Higman discusses the current priorities for the ICB in an interview with Healthcare Leader’s editor Victoria Vaughan.
Victoria Vaughan What are your top three priorities for the ICB at the moment?
Jonathan Higman Number one is making sure that we support the population through the winter, but we also want to ensure that we are progressing the strategic agenda. Number two is about the capabilities of the system and working with system partners so they understand the opportunities of ICSs and ICBs and why they’re different to what’s gone before and how we work differently. It’s all the stuff about the cultural change, that you need people to think ‘system’ rather than ‘organisation’ and putting population health management at the centre of that.
We’ve got a strong public health department in Somerset but the move to putting population health at the centre of our thoughts and planning is a new one. There’s a lot to do around how we get the ICS up and running in a way that makes sure that we’re focussing on what we need to for the future.
Number three is redefining our strategy. In Somerset we’ve got a history of strategic work, we’ve worked with the council on Improving Lives which is our overarching health and welfare strategy within the county and we’ve interpreted that into Fit for my future, which is the health focus of that. The ICS has come along with a slightly different focus around prevention/early intervention. There’s an opportunity now for us to state that and really state the direction of travel over the next five to ten years.
VV Somerset has been working as a whole place for a while how helped in the transition to ICBs?
JH One of the real opportunities of Somerset as an ICS is place and system are the same thing. We’ve got a single ICB, we’re moving towards a single council – they’re going through a process at the moment to go from four districts and a county council into one unitary authority. That will be up and running from the April 1, 2023. We’ve also got a merger of our foundation trusts. During the last five years we’ve gone from three FT’s to two and we’re moving to one, with Yeovil and Somerset Foundation Trusts merging.
Somerset Foundation Trust was a merger of Somerset Partnership and Taunton and Somerset, which is effectively Musgrove Park Hospital in Taunton. That happened, about three or four years ago, and now Yeovil is joining that. There will be two acute sites, mental health services, community services and that organisation also has primary care subsidiaries including Symphony healthcare services which runs a PCN.
We’ve got one footprint, one health and wellbeing board which is the same as our ICP. There’s no point in having two meetings with largely the same agenda. I suppose we can describe ourselves as being relatively neat in that sense. We’ve got good engagement with the voluntary sector we’re trying to develop that through Spark, which is a local organisation that coordinates that sector. Then we’ve got primary care coming together through a primary care board with a link through to the ICB board.
VV Is the primary care board countywide as well?
JH Yes at the moment it’s a GP board but they’re looking at membership becoming wider as we take on delegated responsibility for dentistry, optometry.
VV What is your view of primary care services in your area and how’re you working with primary care at this point?
JH I look at the stats. Primary care is delivering more activity than it’s ever delivered. I’m not sure that message is always out there for people. They’re doing huge amounts of work, they’re doing work in a different way. Somerset has got a history of really strong primary care and we’re keen to make sure that we’re able to support independent primary care in the future. We’ve also got this model through Symphony Healthcare Services which runs 20 sites, 16 contracts out of the 63 in Somerset so that’s just about a quarter of all primary care falls under Symphony. Symphony is an arms length subsidiary of Yeovil Hospital so it was set up very much to support practices. It was part of the Vanguard programme so there are two arms to that, one was about new care models which was about complex care management and supporting people in their own communities in a different way and the other one was about how do you support the sustainability of primary care as we go forward. It started off in South Somerset but a number of practices across the county have become part of Symphony. I think it’s in nearly all PCN’s and there’s one PCN South Somerset West PCN that’s entirely Symphony practices.
VV Do you feel like you work more with practices, your PCNs, your board or Symphony?
JH One of the issues for an organisation like the ICB is how you get down and really engage with individual practices particularly at a point in time when everybody’s really stretched and they’re just trying to do the day job. We tend to engage through the primary care/GP board and through the PCN clinical directors but it’s early days in that engagement. I think we’re trying to find the best way of doing that because we’re keen whoever comes and is part of board conversations has the mandate for primary care. Obviously we’re also working through the LMC as well, who in Somerset have historically been strong and active and a really positive partner and they were through the CCG and PCT days so we’re keen to develop that.
VV How much are you focusing on the Fuller Stocktake and this idea that PCN’s are going to evolve into integrated neighbourhood teams in terms of your primary care strategy?
JH All of these things are very much points of discussion at the moment. At present we’re developing our primary care strategy so the idea is we have that by December we have a Fuller primary care strategy that addresses ‘How do we want to work and develop PCN’s? What’s the relationship between independent primary care and organisations like Symphony Healthcare Services? What do we want to do in terms of the clinical model within primary care?’ Because there is the whole thing about on the day demand and managing long term conditions.
There’s probably a whole array of views on it and we haven’t landed in Somerset on a definitive model but I think there’s something in it. We’re trying out a couple of things so South Somerset West PCN has put forward a proposal to work differently across two of the practices so effectively one becoming a hot hub site and then the other one then focussing on the long term condition management of the patients across those two sites. We’re looking to support that and that will be an interesting test case. We’re also looking at the relationship between primary care and some of the minor injuries units in Somerset where historically there’s been challenges with consistency because of workforce and so that leads to issues with opening hours and people knowing what’s available when. Is there an opportunity for us to work between primary care and the MIU’s to do something different there? It’s early days in these conversations but I think even in a rural geography there is opportunity here to do something differently.
VV When you say you want to support this test case does that come with financial backing from your ICB?
JH Potentially. We’re looking at the moment to see how far you can go with the existing two contracts within the two practices because they are both run through the same organisation so it may not need formal merging of the contracts it might be that they can just run differently. We’re saying to them, ‘How far can you go with what you have you got?’ But also we’re definitely up for putting some additional resource in should that be necessary.
VV I think some of the less ‘neat’ ICB’s are looking to delegate a lot down to place and primary care collaborations, is that something you’re wanting to do?
JH We haven’t really got into that conversation yet for a couple of reasons. One, because I’m not sure the PCNs have quite got to a point where they are able to take on that responsibility, a lot of them are part time so we’re having some very positive conversations about, ‘How do we make sure there’s enough capacity, how do we make sure people feel supported?’ That’s the first thing and then the second thing is part of the changes to local government the council are consulting on at the moment are the footprints for local community networks (LCNs) and they’re really keen to delegate a whole load of stuff down through that route in theory. We’re just working with them to say, ‘Wouldn’t it be neat if the geographies of those were coterminous?’ One might be a bigger footprint and incorporate a couple of the PCNs, but it would be really good if they linked together because you could then look at communities and say, ‘What is it that as health and social care, or health and a local authority we could delegate down to enable people to take responsibility for delivering improved outcomes?’ The ICS can then be much more outcome focussed rather than on specific input measures. Use population health, use the analytics that we’ve got, target inequality in populations, provide some sort of steer over that but don’t mandate necessarily what the solution is because that comes from within the communities and actually if we could align the LCN’s with the PCN’s then you’ve got one group of people who are looking at the same geography and they’re able to move some of that forward.
VV And in terms of those health inequalities what are the priorities in your area?
JH It’s early days. It’s things that you would probably expect like coronary vascular disease outcomes. There was some surprising data for us around suicide rates in Somerset particularly in men of a certain, middle-age bracket. So there a couple of things that came out of the data that surprised us. Diabetes and coronary vascular disease are the two big ones for us. And the outcomes are differential in the areas you would expect in lower output areas where we would need to target our input.
VV Are you looking for the solution on how to tackle that to come from the ground up?
JH A lot of this is early days stuff so we’ve set up a population health programme which we are working with the local authority. It’s being led by the director of public health for Somerset and the idea is that starts to identify priorities using the data but then from a solution perspective, we get to a point where we’re working with communities to work out what the solution is. Some of that came out of the pandemic and the vaccination exercise where we were designing services and people were saying, ‘Well, that’s all very nice, but I don’t think I’d ever access it like that.’
There’s something about finding the balance between looking at things across the whole of the county, and making sure we are being consistent in our approach, and local delivery of solutions. We’ve got to try and find the right balance between the two, so we don’t have completely different priorities everywhere, you know, a thousand flowers blooming, but at the same time, not mandating solutions to communities and people going, ‘Well, actually, that might work in Bridgewater or in Chard, but it’s not going to work for me here in Crewkerne.’
VV How is recruitment in your area?
JH I’d say it was a challenge, and probably the biggest challenge. Of all of the things that we look at, we’ve often got good ideas, we get a bit of a sense of a place where people are pretty engaged around the solutions. But, the challenge is always ‘well, that’s fine, but where are we going to get the people from?’ There’s a few things that we’ve done that’s helped. We’ve had quite an active overseas international recruitment process that was being developed out of Yeovil hospital, which is now supporting Somerset and,16 or so other trusts around the country, because of its success.
VV Where are you recruiting from, have you been to specific places?
JH Historically, it was focused on Dubai, because they train international nurses. The focus is there and in the UAE. We’ve got that bit, then we’ve got the bit about how we train our own people. Historically, Somerset hasn’t had its own university, which has always meant that young people leave and go elsewhere to train. Just this year, we’ve got a partnership with Bridgewater and Taunton College, who are I think are the first tertiary college in the country to have NMC-accredited degree programmes, which are run out of the University of the West of England, on-site in Taunton. I met the first cohort going through the nurse degree apprenticeship programme, in Taunton, across the road from Musgrove Park Hospital. On their site, they’ve got apprenticeships, degrees, and T-levels all being run there together.
We’ve also just started on a programme where we’re supporting people who historically may not have accessed careers in health and care. People who are unemployed, people the Department of Work and Pensions have referred to us, and people who have volunteered and come forward from the vaccination programme and, wrapping a programme of careers, education and guidance, training and work experience around them with a guaranteed interview at the end of the programme.
VV Is that an ICB programme?
JH That’s been through our workforce programme, as part of the ICB, yes. And, I think, it’s really early days but the programme with unemployed people has got something like an above 90% retention rate for the people who get to the point where they have an interview and get a job. I think we’re at three-month retention rates at the moment. It’s a new way of trying to find workforce, and just trying to think about how we access people that may not have thought about health and care as a career before.
There’s a benefit to us in terms of local training, local provision and not losing people elsewhere in the country to do their training who never come back or don’t come back until later in life, and also supporting career returners and people who are maybe picking this up as a second career.
VV In terms of your financial position, how is that at the moment and how are you approaching that?
JH It’s fine, we’ve been breaking even for the last couple of years, we are forecasted to this year. We’ve got some risks around things like escalation costs and the staffing associated with that, but we’re on track to break even this year. I think as we go forward from next April, it’s going to be a more challenging position and depends what happens with public spending, as well. We’re focused on the things that we can do now that will get us through a tougher economic climate as we go forward from next April.
VV You’ve got quite a lot of change happening all at one time, so how are you thinking about that risk with your unitary authority, your hospitals merging and your relatively new ICB?
JH It is a lot of change at once, but I think from a risk perspective, the risk is definitely outweighed by the benefit and so, in the way that you would expect us to, through risk registers and good governance, we’re watching the impact of that and we recognise it as a risk. But, our view is that the processes seem to be working quite nicely at the moment. People are still engaging, despite all that organisational change and engaging in the things that seem important.
VV Where do you hope to be in a year’s time?
JH It goes back to the three priorities. Success would be that we work, and we work with partners, to deliver a successful winter, because that’s the thing that’s right there in front of us. At the same time, we make progress around our capabilities working as a system. Linked to that, there are some really tangible things around the short-term pressures around hospital discharge and enabling that. That’s key to enabling the winter such as the virtual ward rollout, being a really key new model of care. I’d like to sit here in 12 months time and see some really tangible new things that, as an ICS, have come about because we worked together. Things like a new approach to hospital discharge, the virtual ward programme and therefore the consequence of that being that we manage what was going to be a really tricky winter successfully for the population.
The things around workforce and workforce resilience, and being able to support innovation around workforce, would be a really successful thing that is specific to Somerset. There’s some national stuff, but there are some specific issues in Somerset like the retention rate of young people in Somerset because they go off to university and so, for us, to have made further progress on that.
And, I think for us to really have shifted the dial around population health management and put health outcomes and inequality right at the centre of our planning. I guess a success would also be, as we go through the financial planning for next year, all partners in the system agree that we should be putting our growth money into early intervention and primary care, anticipatory type models of care, so that actually, we’re taking a longer-term view of supporting the health and wellbeing of the population. The stats in Somerset are probably not that different to anywhere else, but I think we’ve got something like a life expectancy of about 84 in Somerset, but a healthy life expectancy of 64. So, we’ve got 20 years where people are not living in their best health. If you put that at the centre of what you’re doing, and you develop and you look at your priorities around trying to narrow that gap over a period of time, that seems like the difference the ICS can make.