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Integration Inquiry: Devolution and Commercialisation

Chaired by Lord James O’Shaughnessy and Professor Mike Bewick, the second inquiry session of the NHS Innovation and Life Sciences Commission took place on 26th June. This session focused on achieving greater integration of health and social care services, bringing together the recommendations of leaders in healthcare, life sciences and local/regional authorities. The discussion opened the potential of innovation as a solution in the innovation agenda.

The second inquiry session of Curia’s NHS Innovation and Life Sciences Commission contained a rich discussion on integrating health and car services, aided by the distinguished panellists of thought leaders.

The second half of this inquiry session focused on supporting ICS integration and bringing the life sciences sector into the integration agenda. The panel for this session were:

  • Jon Rouse – City Director, Stoke-on-Trent Council
  • Professor Des Breen – National Clinical Advisor for System Transformation, NHS England/Improvement
  • Dr Claire Fuller – Chief Executive Officer, Surrey Heartlands and Care Partnership
  • Richard Murray – Chief Executive, The King’s Fund

Achieving autonomy and integration for ICS

The first topic of this session focused on how ICS’s can retain autonomy to innovate freely whilst also achieving significant integration of health and care services. Dr Claire Fuller explained as a Chief Executive of an ICS, she is accountable for the financial sustainability and delivery of the system. However, there is a statutory responsibility to meet as part of the NHS system. Dr Fuller noted the existence of an Integrated Care Board (ICB) and an Integrated Care Partnership Board (ICPB), which gives the ICS leadership both democratic and statutory accountability. She added that if there is focus on just the ICB agenda, the potential of ICSs to establish true partnerships and address wider determinants of health will be diminished.

“The NHS on its own can only improve health outcomes by twenty percent. Unless we work across the full partnership, we are not going to maximise the outcomes for our population” – Dr Claire Fuller

Jon Rouse explained his experience of having the “wrong conversations” in accountability meetings, which focused on measurements such as waiting times but not health outcomes, quality of care, or quality of aftercare. He added there is a tendency in NHS leadership to focus narrowly on a relatively small number of process measures; the NHS must then align with the ICS interest and national interest.

Rouse added the issue of resources he faced as Chief Officer of Greater Manchester Health and Social Care Partnership. He explained having transferred transformation resources from the national level to Greater Manchester, he was confident resource allocation and decision-making were more efficient. Rouse added the combination of access to resources and the right leadership was essential when dividing resources across different areas.

Following Lord O’Shaughnessy’s point on whether ICS have the freedom or confidence to reject national targets, Dr Fuller noted that ICSs are currently monitored on their constitutional requirements. She said that until these are met uniformly, ICSs won’t have that degree of freedom. However, she added that the strategy of her ICS will be focused on local population needs, experiences and access to improve outcomes and reduce inequalities. She added these outcomes will be measured by the ICPB rather than the ICB and the latter will be for more traditional, constitutional NHS targets. Rouse agreed that the freedom and confidence is not there, but suggested a compromise was needed to accept a minimum number of national targets to combine with local targets. NHS England as the central body must then take interest in local indicators so that it can establish the needed, balanced conversation.

ICBs finance planning to prevent competition for resources

On the issues of delegating finances, Professor Des Breen noted the need for a “behavioural change” in ICBs to adequately allocate resources effectively. He added this was not a “panacea” and would take time to develop.  He argued the ICBs don’t currently have total autonomy but will slowly be able to tackle priorities in population health, health inequalities and wider strategic commissioning.

“It’s about shared purpose. It’s a cultural change. It’s a behavioural change. It’s getting the things that we want to achieve and getting the members of the ICB to actually commit and do it”. – Professor Des Breen

Professor Breen explained the need for personalised care to be at the heart of the agenda, which will allow ICBs to strategically commission and find solutions to the “problems to solve” rather than the “targets to hit”.

Richard Murray noted the existence of a “mirage of control” in the financial autonomy of ICBs from NHS England, arguing for the financial system to be more straightforward. He added the importance for ICBs to gather analytical support based at a place level. He noted that NHS England and the Department of Health and Social Care have allocated resources effectively when this has been shown previously.

Murray explained the disparities that exist between regions which previously were Care Commissioning Groups matched with the local government structure and other areas that are now organising these structures. For this reason, conflicts between place and provider collaboratives are going to be a process. He added the real challenge exists with the other imbalances that exist within ICBs, mainly ensuring primary care, local government and the voluntary sector have a voice in the delegation of resources from providers.

On Richard Stubbs’ point on how a restructure could be implemented, Murray explained the need for the role of partnerships in assessing if the ICB is delivering on what is agreed and to check resources are allocated appropriately. He noted the difficulty of burdening ICBs with the representation of all voices, yet methods to bring in a wider number of bodies into the decision-making of the ICBs are needed.

Professor Breen added most transformation does not happen at the ICB level, which are only “peppered by the right types of stakeholders” and is instead found at the ground level. He noted the ICBs hold an opportunity to be very inclusive and stick to outlined principles, but unless steps are taken the new boards risk becoming “too NHS and too acute focused”.

Integrating the life sciences sector into the integration agenda

Rouse gave an overview of his experience in Greater Manchester Health and Social Care Partnership in providing a dedicated space for collaboration with the pharmaceutical and biotech industries. He noted that the success in integrating the life sciences industry was due to creating Health Innovation Manchester, an innovation hub with its own governance structure and accountability mechanisms. It was entrepreneurial with a “light touch gateway process”, allowing innovation. He added the system in Greater Manchester allowed a “push and pull” with the life sciences industry – so that solutions were a two-way process. Underpinning this success, Rouse explained the Greater Manchester Care Record provided anonymised datasets that supported individual research projects and was vital to this success.  He concluded that innovation hubs across the country could achieve the same.

Professor Breen furthered the point that the life sciences industry must be embedded within ICBs and innovation hubs, to support the collection of the right data and the right interventions. He added the incorporation of life sciences companies could support the data infrastructure and subsequently, improve visibility of health issues for the NHS. Professor Breen noted the potential for “co-design” between the NHS and industry, yet the life sciences sector could be more flexible in the transfer of research from controlled environments to the uncontrolled environment of public health.

Shared practices, cultural change and data collection to ensure adoption

Rouse shared case studies of success during his time at Greater Manchester Health and Care Commissioning. He explained that an ongoing program is the embedding of chip technology into fitted heart devices, which allows remote monitoring and inputs into a wider algorithm for the prediction of traumatic events. He added another example of success in the ‘Polypharmacy Project’, which targeted elderly patients taking more than ten medicines. The project worked out which combinations were having adverse impacts. Rouse explained the problem was the lack of a mechanism to take this learning into national consideration.

On Professor Leng’s point on which institutions or bodies would provide this mechanism, Professor Breen added the Academic Health Science Networks could have a real part to play in supporting this. However, he argued that the rollout will need to start in a few areas and then multiply nationally.

Professor Breen gave the example that ten high-impact interventions were passed two years ago, yet only half were adopted into the whole system, some of which had plausible concerns whilst others should have been adopted at scale. He added the financial cost of adoption is a drawback and implementing a “safety scan” to improve safety would add to such cost concerns.

Dr Fuller argued the reason innovations are not being adopted at scale is the absence of a “theory of change” and delivery program at the national level. She added the NHS must improve on describing to clinicians the impact and benefit for patients, as this will drive change quicker.

“Often with the interventions that we’re talking about, we will target a sector rather than a pathway. The examples of things that have worked well have stayed within a sector, but actually will be targeted upon by hospital clinicians and then fails when it comes out into the community; either because of different funding models or because of different distribution models” – Dr Claire Fuller

Murray noted the adoption of innovation is “something people should want to do and that “sells itself”, meaning the influx of “performance management” could be restrictive. He added to previous points regarding the ICBs having to answer to larger providers, therefore adding transparency are understanding is essential for both parties.

Final thought

The second hour of the inquiry session looked in detail at the devolution presented with the new integrated care systems and the opportunities for commercialisation. As a trailblazer in the area of integrated care systems, Dr Claire Fuller was exceptional in explaining the opportunities, as well as the difficulties that must be overcome for care to integrate successfully. Given the new system is in it’s infancy, the results are yet to be seen.

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