Devolution from Whitehall was one of the big ideas of David Cameron’s Conservative government. ‘Devo Manc’ was up and running by 2015 and partnership working has been in place since then. However, while historic relationships provide a solid foundation, the pressures are still massive. NHS Greater Manchester’s CEO Mark Fisher talks about plans and priorities in the area with Healthcare Leader’s Editor Victoria Vaughan.
Victoria Vaughan: Can you give an overview of your integrated care board (ICB), particularly with regard to Greater Manchester’s devolution deal?
Mark Fisher: The Greater Manchester ICB is one of the largest in the country. We have a population of 2.8 million to cover and it’s a population with probably a higher level of inequality and health challenges than many others. The major difference from other ICBs is the history of devolution in Greater Manchester, which has brought with it a real inheritance of closer working, particularly between the NHS, local government and the mayor. When I arrived in the ICB on July 1, I was very positively struck by the nature of the relationships there are in the Greater Manchester system – the relationships are really strong and that is a real positive for the future.
Having said that, probably like every other NHS ICB in the country, the head winds are also strong. Like many others, we face significant performance pressures, population health pressures, unmet demand, and waiting lists – really serious issues. But I do think those strong relationships give us a really great foundation on which to confront those problems.
VV: What three things are you choosing as your priorities in the ICB?
MF: Waiting lists are the first priority. We have to enable the system to reduce those waiting lists, to deal with the winter pressures and flu and COVID.
Priority number two is to work with our partnership to develop a strategy for the future. That’s a strategy in which primary care has a very significant part to play. By focusing on prevention – and on the mode of primary care and that integration we have with social care – it will enable us to reduce demand and get off this endless hamster wheel of pressure. We can’t sustain the amount of pressure there is in the system and our strategy is designed to move on and learn from that.
And the third priority is balancing the budget. There’s a degree of financial discipline that we have to maintain across the whole system.
VV: How is the ICB going to help the system cope with these things?
MF: Because we look at the whole system, we can bring about an integration and a focus that individual parts of the system cannot do for themselves. For example, we are putting a great emphasis on primary care access – how do we enable primary care, through the networks and other parts of the system, to really improve access?
We’re also putting a major effort into social care integration. How do we ensure that there’s nobody away from their home a day longer than they need to be? How do we get that integration with social care? And, actually, it is only the ICB that can do those things in the system. So that’s what the ICB will bring – a focus on population health, primary care access and social care.
VV: What are you hoping to do with primary care networks (PCNs) around access?
MF: Well, we have a blueprint for primary care, which will be out at the end of April, which is building on lots of great work that’s been done across Greater Manchester over the past few years. It’s really trying to do two things.
One is putting primary care and the PCNs at the hub of the work going on in their communities and localities. They bring the whole infrastructure and resources to benefit the health of those populations. For example, working in schools, with community groups, the voluntary sector, using things like social prescribing – it’s putting primary care at the centre of things.
And the second is to make sure that by primary care access we don’t just mean access to a GP. We mean access to a whole range of services that primary care can facilitate and engage. I was at a great practice in Middleton the other day where you contact the practice and they rapidly refer you to one of a range of people who can meet your needs, which may or may not be the GP. It could be a nurse practitioner, paramedic, or a social prescriber.
Many people who present have a social problem – they don’t necessarily have a health problem – and the right answer is to get the social prescribers to help them with their housing, debt advice, or whatever is causing the problems. There’s a whole range of support services.
VV: Where are you on tackling health inequalities?
MF: We want to build on the foundations that the devolution deal has enabled. There was a really interesting article in The Lancet a month or two back showing that devolution itself had led to increased life expectancy in some of the most challenging localities. I thought that was really powerful because it shows if you integrate public service, if you make health everyone’s responsibility from the mayor, to local government employers, you can address some of these long-standing fundamental problems. It’s a key element of our strategy that we continue a focus on population, health and prevention as well as on the acute.
VV: How do you balance funding urgent issues against spending money on prevention initiatives that won’t have an impact for another 20 years?
MF: One of the reasons why I firmly believe the ICB structure is the right structure is it enables you to make those decisions in the round. So it’s obviously like every other ICB in the country, we’ve got a major challenge to reduce waiting lists and living within our means, but we will have failed if we don’t also prioritise population health and upstream prevention. But I won’t deny there is a tension in that.
VV: How are you going to change the way you fund primary care to acknowledge this move towards a greater focus on health inequalities?
MF: Funding in primary care is driven directly by the contracts, so the change in the ICB will be up to primary care funding and probably at the margins of the conversation really, because most of it is driven by the national contracts for one thing or another.
VV: Is that something that you think ICBs have the power to lobby on or discuss with NHS England?
MF: We definitely do discuss and lobby with NHS England about changes we ought to make and other things we would like to see in those contracts, but I’m not one of these people who thinks the right answer is to devolve those sorts of contracts to ICBs because that would be an immense amount of work and we need to leave those national arrangements in place.
VV: What’s your current view of your primary care services?
MF: I just think there are some amazing people, whether they’re general practitioners or any of the other professions, they are doing fantastic things in some of the most challenging circumstances. I’ve been out and about quite a lot into different parts of Greater Manchester since I started in July and I’ve seen practices really innovating in how they deal with the health needs of their population, particularly around things like social prescribing. And organising themselves to bring the range of professions and the range of different ways you can help people to bear. So, my initial view is I just want to see more of that, and that is obviously at the heart of our blueprint due to be published at the end of April.
VV: How does that square with morale at the moment and potential workforce issues across your patch?
MF: Like every other part of the country we have workforce issues, whether that’s in primary care or in other aspects of the health system – we have large vacancy rates pretty much everywhere, actually. We have a workforce strategy, we work very closely with our local universities and the further education sector, and we’re also pretty focused on things like wellbeing and retention to try and enable people to basically stay at work longer.
But the fundamental problem is we’ve got to get the system off this hamster wheel of endless ever-increasing demands, because it seems to me we don’t have a completely sustainable position. That’s reflected in some of the workforce challenges we face. We need to give a bit more hope to the system that it is possible to get people’s workloads to a more manageable state. If we can do that over a few years, it really will feel like success. And if we’re still on this hamster wheel in five years’ time, we won’t have been doing our jobs properly.
VV: It’s often said that creating more access creates demand. Do you have conversations around this idea that serving the demand creates more demand?
MF: We do have conversations about ‘serving demand creates more demand’, to use your phrase, but we have to get beyond that because we have to serve the demand and serve the created demand at the right place in the process because the demand bubbles up somewhere. But if you can service the demand, for example, in the community, in the neighbourhoods, in primary care, it’s a lot better for the system than servicing in an A&E department or downstream when somebody is simply having to be treated for an illness or an ailment that might have been treated better in a primary care setting. We have to face into that issue, actually.
But I also think, going back to the point I made earlier, quite a lot of the demand we see isn’t actually a medical demand, it’s a social demand – and there are other and better ways of dealing with many of those problems than medical intervention.
If you can equip primary care with people like social prescribers, if we can do more – for example, we have one for living well programmes in many boroughs in Greater Manchester which are all to do with non-medical intervention. For people with mental health problems, non-medical intervention is often a much healthier thing to do than a slightly delayed medical intervention, so we can meet unmet demand – we just need to be imaginative about how we do that.
VV: What is your ICB’s approach to the Fuller stocktake and are how you working to implement it?
MF: Our primary care blueprint, which Greater Manchester has been working on for some months, is our implementation of Dr Claire Fuller’s report.
VV: The other big piece of work that is due to be published soon is the Hewitt Review. What are you hoping the outcome of that might be?
MF: I mentioned two things to Patricia Hewitt. One is that I’m hoping the Government will have a bit of what I describe as strategic patience. We’ve set up ICBs, they are in my view the right answer, we just need to give them some time and resources to do the job they’ve been asked to do.
The second thing is that the logic of the ICB model needs to be followed through. That is, the reform of NHS England and the creation of ICBs moves in parallel. For example, when hospitals are in trouble, or there’s performance management to be done, it’s done through the ICBs, not around them.
Our ICB is still in build mode, so, strategic patience is probably the most important thing we need to see now and the completion of the model, if you like.
VV: What else do you need to do to build the ICB?
MF: We’re still in the middle of quite a significant staffing transition because Greater Manchester is creating an ICB out of 12 predecessor organisations. So, there’s quite a lot of reorganisation to be done and we’re definitely trying to fly the aeroplane while we’re still putting the wings on – it feels like that at the moment.
VV: What is your current financial position and how are you hoping to tackle the deficit?
MF: We’re reporting back to NHS England on our end of year financial position, and we’ll be in a reasonably good place by the end of the year.
Going to next year, like every other ICB, there’s a lot of effort now going into how we deliver everything because we need to deliver within the resources we’ve got. But that’s a process we’re in the middle of so I’ll just wait and see before I say more about how we’re going to do all that. All I know is that a lot of great thought and complicated work is going into how we manage to deliver more in terms of activity particular around things like elective care within the envelope we’ve got.
VV: When it comes to hearing from the different sectors, you’ve got a broad brief. Do you feel that you’ve got a cohesive primary care voice coming through?
MF: We have primary care on our Board, we have a primary care collaborative, so I would say the voice of primary care in Greater Manchester is very strong. And I also would say simply the ICB is not doing its job properly if it does not listen to primary care, because going back to our strategic direction, actually working with colleagues to improve access, to improve service, is one of the absolutely fundamental things we need to do to achieve our strategic ambition. So, if we don’t listen to primary care we’re just simply not doing our job properly.
VV: Greater Manchester has run dentistry, pharmacy and optometry since devolution, so what’s your advice for ICBs taking it on from April?
MF: Actually, it’s a really powerful and positive thing to have those aspects of commissioning devolved to you. It’s made a massive difference in Greater Manchester having that within our commissioning portfolio if you like. So, I would say bring it on.
VV: In what way is it powerful? What have you been able to do with those services to better serve your population?
MF: The blueprint demonstrates that it’s emerged from several years of working very closely between the Greater Manchester partnership and the primary care world, and we’ve had that direct relationship. The partnership was the ICB’s predecessor body, and we’ve had that direct relationship for quite a long time, and that’s enabled us to have a very mature developed integrated conversation with primary care colleagues about how things should be. And the fact we were the commissioner has really added value to that conversation.
VV: What’s your ICB’s role in the social and economic regeneration of your area?
MF: Well, rightly, we’ve done quite a lot on that already. For example, we’ve been working very hard with the Mayor and other colleagues about the position of the NHS as an anchor institution in Greater Manchester. We offer great jobs, great employment prospects, particularly for people from disadvantaged communities, and, so, we are positioning ourselves as what we call anchor institutions. Not all, but many NHS institutions are able to pay the living wage, for example, which is great.
In Greater Manchester, we have a good employer charter which is all about being a good employer in the round, focusing on things like the living wage but also on wellbeing. So, we are trying to be an exemplar employer in Greater Manchester, and we’re trying to position ourselves further as anchor institutions offering great employment prospects, great jobs for local people, and that’s one of the best things we can do as an employer.
Also there’s lots of great innovation and research practice. We work with the local universities on innovation research, and we are trying to position ourselves as a place where big pharmaceutical companies want to come and do business using our health capacity and data. So innovation and research are other areas where we can contribute to the wider economic good of the population.
VV: In a year’s time, what would success look like for your ICB?
MF: We need to have further reduced waiting lists and moved closer to our strategy targets on things like A&E attendance. But I also want to see further improvements in primary care access and fundamentally reducing the demand for hospital services because of work in the community. I want to see that direction of travel firmly embedded and progress against it. That’s what success looks like.