NHS Bedfordshire, Luton and Milton Keynes covers a diverse area with a rapidly growing population where more than 150 languages are spoken. Chief executive Felicity Cox discusses the current priorities for the ICB in an interview with Healthcare Leader’s editor Victoria Vaughan.
Victoria Vaughan: Could you start by giving an overview of your area?
Felicity Cox: We cover Bedfordshire, Luton and Milton Keynes, which means that we have four local authorities in our area. Bedford borough, central Bedfordshire, Luton and Milton Keynes. They are very, very diverse. From Milton Keynes, which I would describe as an ageing new town that’s now a city, through to very rural countryside. Across the ICB, more than 150 languages are spoken.
That means we’ve got everything from rural to urban deprivation, we’ve got high levels of employment in most of the patch, but we’ve also got quite a large population of degree-educated women who don’t work, who could work.
The variation in life expectancy is huge – 10 years across different parts of the patch, but on top of that the variation in healthy life expectancy is quite stark, it’s 19 years across our patch, from the best to the worst. ‘Old’ in Luton is probably 15 years younger than ‘old’ in Central Bedfordshire.
We’ve got a population of over a million, but it’s scheduled to grow rapidly in the next 10 years to about 1.2 million. We’ve got two of the highest growing boroughs in the fastest growing region of the country. Bedford Borough and Central Bedfordshire both grew by approximately 16% last year.
One of the unique things about us, is we are very keen to do research and we think that the diversity of our area and population means that you can probably research just about everything here.
VV Are you linking up with anyone around that?
FC We have become a research ICS. We have got a research hub that we developed with the University of Bedfordshire and we’ve got Cranfield University and other partners involved in that as well. Part of that is about developing our own research capabilities amongst the people that work in the patch.
VV What do you want to research?
FC We’ve got four clear areas. We’re looking at an inclusive workforce and building resilience, at our research capacity, at innovative ways of working and safeguarding children and adults with complex needs.
We’re looking at how we can bring our own population into the workforce, because we know that the best-paid jobs in our part of the world go to people that travel into the area.
VV What are your top three challenges at the moment?
FC The key thing is for us, developing a clear strategy around which all our partners can coalesce.
You could get sucked into doing things in the same way that the NHS has always done them. The opportunity for ICBs is to use their partnership working and convening power to add value and bring together people in a different way, not just double do somebody else’s business as usual. Our strategy needs to encompass all the NHS day-job things, but it also needs to show what the ICB will do to add value.
Then sustainably managing flow across the system, focusing on admission avoidance and reablement, not just discharge. For me, that’s important. It’s a today issue. It’s important because that’s our license to operate, to do the more complex work around inequalities, to work on the longer-term, the prevention agenda. If we don’t sort that bit out, we won’t have the room to get into those other areas.
Then the last one for us is, obviously, we’re built on the principle of subsidiarity and it’s developing priorities and plans for Places which enable us to be sensitive to that variety of populations we’ve got, so that we really tailor the care to local people and deliver everything equitably. That will be a big part of how we develop our Fuller neighbourhoods because, it’s absolutely crucial that the primary care networks (PCNs), the Fuller neighbourhoods, are built in as part of Place and can provide in the way that their population wants them to.
We had an interesting meeting a couple of months ago with our PCNs, where the head of housing came to speak to them from one of our boroughs and said, ‘I get letters from GPs asking me to rehouse people. We have no housing stock to rehouse them.’ A more useful conversation might be, ‘These are the issues with their housing. Can you do some work around remediation?’
VV Was that well-received by the PCNs?
FC Yes, because the GPs realised they were wasting their time. That it was a great time saver for them to think, ‘Actually, that’s not the right approach.’ We know that a lot of GP consultations are people asking about things that are not to do with their health.
VV In terms of those three priorities do you have a strategy on how to meet them?
FC It’s early days. What we will have is a launch strategy that gives us an overarching goal that we will all aim for and a lens by which we’ll judge our system – that is levelling up the healthy life expectancy gap.
From there it’s about how we create the interim goals that will help people get there and how we make sure that we’re constantly looking through that lens and asking, ‘Will this make a difference? Are we levelling up our population? Are we managing to do it in an equitable way, not just an equal way?’
Our strategy, I hope, will be a short document supported by a lot of detail, rather than a huge document with everything in it. [It will say] ‘Here’s what the ICB does, here’s where we, as an ICB, add value, and here’s everything else going on in our organisations.’
VV From April, you’re taking on more primary care services what do you think the ICB can do there to help?
FC One of the great added values of the ICB is convening power. I always knew we had that, but I didn’t really think about the importance until some of the retrospectives of Prince Charles as Prince of Wales. One of the things he was credited with is, using his convening power and, effectively, restarting the British cheese industry. I thought, you forget the importance of just bringing people together, to look at problems together, to work together. I think, we can add value in that way, but also, we have resource that we can put into those spaces, from the ICB staff, that can actually support the clinicians who will have the brilliant ideas.
VV Who from the ICB will support clinicians in this way?
FC We’re talking about change and transformation resource. There are probably about 70 of us who are clinical in my team, but it’s more about the change and transformation skills, because the clinical nous will come from people working on the frontline, it won’t come from people sitting in an office.
VV Are you deploying any of those change and transformation people into a hospital or community setting at the moment?
FC At the moment, we can align people, so we’ve aligned, it doesn’t sound a lot, but about six-and-a-half people into Milton Keynes, because they’ve already developed their Place deal and the core things that they want to work on. We hope, over time, as we start to refocus our organisation on transformation and change, that we’ll have some people who are embedded at place and some people who are a flexible resource, who can be drawn in, to work on particular areas.
VV In terms of developing the neighbourhoods and PCNs, what’s your view of primary care in your area at the moment?
FC Undoubtedly, primary care in our area is under pressure. Our primary care clinicians are seeing more people face-to-face now than they did before the covid pandemic and we have opened lots of channels into primary care without adding any additional resource particularly, and that, for me, is a big worry.
Something has changed in our population during Covid, and I couldn’t say what it exactly is, but I look at my mum and I can see that she’s decompensated, to an extent, during Covid. She’s less mobile, she’s more nervous of things and so on. I see that in her and I’m sure that it will exhibit itself in other populations.
Some of the people that are turning up into general practice are more complex than they were and also, we changed the model of primary care, with PCNs and additional roles, just before Covid hit. People hadn’t got used to that new way of working.
In some of our practices where they’ve really worked with that, their practice population are absolutely happy to know that their first referral will be to a physiotherapist because they’re the right people to tackle their need, but other people say, ‘But if I’m not seeing the GP, I’m not getting what I need.’ Even though all the GP will do is say, ‘You need to go and see our physiotherapist and here’s another appointment’.
For me, primary care, it’s on the cusp of something that could be really brilliant, but we’ve got to take people with us. I would love to see a national campaign. I would love to see, on EastEnders, somebody saying they went to see the doctor and they went straight to the physiotherapist and it was brilliant and, ‘Here I am out playing football’. If we could cover all the soaps, EastEnders, Corrie, Hollyoaks, Emmerdale, I think then people would start to see why they are seeing the practice nurse specialist or practice pharmacist first and that its going to be a faster and better outcome for me.
The other thing I would say about primary care is the negative publicity that there is around general practice at the moment, isn’t helping anyone. We’ve got people who go to A&E who say, ‘I didn’t bother ringing the doctors because I know you can’t get an appointment.’ When I know that’s not true. I don’t think it encourages people to come and work in general practice. At the end of the day, general practitioners are consultant physicians.
VV When you think of primary care, are you looking to work through PCNs or are you looking at Place level and Fuller integrated neighbourhood teams?
FC We do work through our PCNs and we consider our pharmacists and our dentists to be part of that network. We haven’t yet plugged in as much as we’d like to with optometrists, but our vaccination campaigns were very much done through community pharmacy, as part of the PCN rather than by general practices due to capacity.
Over time, PCNs and Fuller neighbourhoods will become one and the same, but it’s the old saying ‘If you can see it, you can be it.’ What we really need is some great exemplars showing how a multidisciplinary integrated team that includes people from education, local resident associations, local religious groups, all sorts of people, can work around a population to help us make best use of the community assets.
One of the big things that we did during Covid was, we worked with our Luton population to find out what was causing vaccine hesitancy, and to deliver vaccines hyperlocal, to whole families, because that was what would make them come. It’s really getting into, what makes this acceptable to that community? Or what makes it unacceptable and how can we do something in a different way? I think that’s what the Fuller neighbourhoods are about, as well as bringing care closer to the population, making consultant care more accessible, hospital care more accessible, whether that’s virtually or whether that’s by having people working in the population. It’s a huge opportunity for education, always around. Primary and community services can do so much more than somebody sitting in secondary care knows they can do.
VV Is splitting urgent and routine care in primary care something you’re looking at in your area?
FC We are looking at that and, in fact, a couple of our practices do that model, of same-day urgent care. We’re trying to integrate 111 into that. We do still have some very small practices where it’s not practical. Luton is a very densely populated area, so people tend not to change practices. That makes it quite tricky for the whole neighbourhood piece, because they’re still part of that practice.
VV In terms of the health inequalities agenda, you’ve got this huge gap in healthy life expectancy, what work are you hoping to do around that?
FC We think that health inequalities is a lens through which we should view everything that we do. That’s our starting point. We are focusing on healthy life expectancy, but we know that 13% of our residents live in the 20% of most deprived neighbourhoods in England, and we’re fortunate we’ve got a leading light Deep End practice – a loose term for the 20% of practices across the country that work in the 20% of most deprived areas. One of the things that a GP in that practice, Dr Yasar Khan, is looking at is what aids recruitment and retention at Deep End practices and how they can better support these practices with a range of initiatives. Some of which are lobbying the government for the same rights for overseas GPs that come over here as they would get in Canada, for example, recognising there’s a global market in medics.
VV What’s the ICB financial position?
FC We are forecasting to breakeven and I expect to achieve that this year. I think next year is going to be much more difficult.
VV Where do you hope to be this time next year?
FC I would hope that people could say they’re starting to see the difference. That people would find services more locally responsive, GPs would be happier, that would be a big win, and PCNs were really starting to engage in Place and get the benefit of being able to tap into local authorities and councils and so on.
Also, what I’d like to see is, although our system is doing well in the East of England, in terms of the national constitutional standards, I would like to see us held up as an exemplar on how you do admission avoidance, how you keep people well in their own homes, and really work in collaboration with local authorities to do that.