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Integration Inquiry: NHS workforce and true integration

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 first half of this inquiry focused on the NHS workforce and what achieving true integration across the NHS looks like. The panel for this session included:

  • Professor Dame Clare Gerada – President, Royal College of General Practitioners
  • Hamish Dibley – Consulting Director, BearingPoint
  • Dr Neil Modha – Chairman, Greater Peterborough Network
  • Stephanie Harvey – NHS Collaborations Manager, Eli Lilly

Freedom for health systems to reorganise staff deployment

The first topic of discussion centered on how new health systems can have the freedom and capacity to rethink how staff are deployed and utilised to achieve greater outcomes and what barriers currently exist to achieve this. Opening the session, Dr Neil Modha explained the main barriers include staffing of the NHS and the pressure on services, rendering other solutions ineffective unless more staff are brought into the NHS. Dr Modha cited the General Practitioner (GP) surgeries in Greater Peterborough as an example of how people without previous healthcare experience can train as healthcare assistants. He noted the need to have faith in the training of staff and establishing trust across the workforce.

Dr Modha explained the place-based agenda , meaning targeting established in Greater Peterborough with a “GP liaison service” to integrate primary and secondary care. He noted the difficulty of integrating different services with different structures. If the NHS can focus on the value added to patients at a fundamental level, he said better ways of working can be achieved.

Commissioner, Dr Keith Ridge asked how the barriers between integrating GPs as primary care “contractors” with hospitals can be overcome. Dr Modha explained that GPs work on fundamentally the same contract as hospitals. He noted there has been significant investment in primary care, not directly into budgets but into the field of Advanced Recovery Systems (ARS) and the Primary Care Management (PCM) agenda. Dr Modha concluded that integration has worked in his GP practice through bringing multiple specialisms together including physios, pharmacists and the voluntary sector to work within and outside the practice. He said, Primary Care Networks (PCNs) encourage primary care organisations to “think beyond their walls”.

Dr Ridge asked whether this applies to all contractor groups in primary care. Dr Modha noted his experience of bringing together dentists, optometrists and pharmacists in Greater Peterborough, which showed that primary care can achieve integration to solve issues for communities and alleviate the pressures on the NHS.

Professor Dame Clare Gerada added the need to reform the legislation in primary care, particularly the performance list legislation and contractual arrangements. Professor Gerada used the example of having an elderly care physician working in her practice, who would still need to have their Responsible Officer (RO) present and this would not alleviate the quotas of numbers under current contracts.

Professor Gerada added the issue of “working to the top of our license” as GP practices and the need for “omnicompetent clinicians” and a multiplicity of providers. In the longer term, she cited the need for all primary care clinicians, regardless of “endpoints”, to work in primary community care. Dr Gerada explained that patients today have complexities and multiple morbidities, meaning every clinician needs to be able to “manage those in their totality”. She noted she wanted to see any non-doctor specialty working in general practice, including primary care clinicians, pharmacists etc. She concluded that proper competency checks must be in place when bringing doctors and nurses into the system, which is a practical issue at the system level that needs addressing.

Delivery of workforce planning and education at the local and system level

Commissioner, Professor Gillian Leng asked how workforce planning at the local system level is co-ordinated and delivered and how that links back to regional and national planning policy. Professor Gerada explained the co-ordination of workforce planning must be led by local teams, moving responsibility for training out of Health Education England (HEE) into the “local area” and Integrated Care Systems (ICS) who are better suited to determine their workforce planning and training.

Professor Gerada added the NHS needs to think more imaginatively about integrating paramedics and pharmacists into primary care, which needs to be incorporated into the narrative at a senior level. She added that workforce planning needs to be moved away from universities.

Professor Gerada also noted the importance of the Health and Social Care Committee’s report in highlighting the chaos and complexities involved in bringing doctors and nurses into the NHS, particularly ensuring they have done the appropriate training. She also raised an international comparison of the Netherlands, which has a long-term outlook in its twenty-year workforce planning agenda.

On the link back to the national level, Professor Gerada noted the need for an overarching body in workforce planning, but this must be more aligned with NHS England than the educational bodies. She noted local areas would not need to develop their own competency frameworks, but they should be able to determine treatment and care around local needs.

Achieving true integration in the health and life sciences ecosystem

Commissioner, Richard Stubbs asked to establish what true integration looks like and achieve this across with stakeholders from across the ecosystem. Consulting Director at Bearing Point, Hamish Dibley explained the need to move away from “silo thinking” in the health and social care system, to a “preventative wellbeing system” that is driven around the identification of the needs of populations. He explained this system must be

locally focused, and place relationships and the continuity of care at the heart of its design – moving away from a “task-driven function design of work”. Dibley added that the health service needs a “responsibility system” that enshrines the principles and practices around continuity of care and around patients – accounting for their experience and outcomes. He added the need to “free up” healthcare professionals so they can lead and manage more appropriate, system-wide interventions for people when they need them.

Dibley noted the importance of performance measurement and explained the current system produces positive results in one part of the system, yet negative results in another. He explained the need for “purpose-driven measures”, a focus on effectiveness and a more holistic approach to the end-to-end effectiveness of treatment and care. To conclude, he argued the need to focus on the reconciliation of money “at the back end, not the front end” and “one budget for one system” which empowers those with authority to spend accordingly with “ownership and continuity”.

“How do you achieve this is always the thing where we’ve fallen down over the last few decades. For me, it’s like how you eat an elephant, it’s one bite at a time. It’s thinking about proof of concepts, not trying to tackle an entirety of a healthcare system overnight.” – Hamish Dibley

In response to Stubbs’ question on whether the health system has all the right stakeholders involved, Dibley argued the discussion around health integration is too narrow. He explained the need to bring down barriers from a medical perspective but also at the managerial level, furthering his previous point on designing services that focus on prevention and have a holistic approach in treatment and care. In terms of agencies, Dibley outlined the need to incorporate the voluntary sector into the system.

As NHS Collaborations Manager at Eli Lilly UK, Stephanie Harvey noted the significant challenges in fostering collaboration both for industry into the NHS and between NHS agents. She explained that given the lack of national strategy and guidance at the ICS level, there is a gap in potential partnerships with the life sciences industry.

Harvey explained that despite the existence of “innovation accelerator initiatives”, these schemes have limitations in terms of their impact; citing her own experience of her work ending up on NHS “playbooks” which haven’t been adopted and scaled. She added that the biggest gap in integration is that clinical teams identify and innovate solutions, however there is no process of taking clear “blueprints” and scaling them. Harvey explained that the current method is to ask clinical teams to get stakeholder buy-in at the higher level in advance, which they shouldn’t have to do. To conclude, she noted how the life sciences industry is trying to be the “change managers” within the NHS, taking on the responsibility of proving concept pilot success when this should be a responsibility of the NHS.

Dr Modha added to the discussion on population health, arguing primary care must focus on wellbeing as much as clinical health in exploring the wider determinants of health. He added the need for an effective data system that would allow primary care practitioners to work more effectively with the voluntary sector and charities.

Assessment criteria of ICS to ensure long-term population health

In concluding the first session, Professor Bewick asked how ICS can collectively be assessed to ensure improved population health. Dr Modha explained the need to progress from a “commissioner-provider relationship to a system that meets people’s needs”, with a uniform thinking that the health system is about the individual’s needs as opposed to budgets. He added the need for data collection and measurements to support the health system and track progress.

Professor Gerada noted the difficulty of setting shared outcomes around continuity, as this differs between primary and secondary care. She added that a positive outcome would be an absence of referral letters, as they signal a “failure of communication and indicate the lack of a shared electronic record and patient systems that can move patients into the right place”.

Professor Gerada noted the “revolving door” of treatment and care that patients face must be addressed. She explained that the current system will move patients between different trusts and refer them to separate healthcare teams when a system with greater continuity is possible. She explained her thoughts of a “week, a month, a year, forever” system, where patients can self-refer into the system, providing continuity across the primary to secondary care interface.

Professor Gerada added that the health system must set itself “brave targets” and move away from “disjointed care pathways into a single health system which ICSs have the potential to be”. She furthered Dr Modha’s point on the impact of data and the “digital revolution” the NHS is going through and the potential this has in establishing a more coherent system of patient placement.

“We are in the very early stages of learning how to use digital consultants and digital systems, but actually the future is there, the future is digital systems supported by AI” – Professor Dame Clare Gerada

Harvey noted the influx of the digital focus since the Covid-19 pandemic, yet the barriers between primary and secondary care still exist and must be lowered to gain the benefits of these developments.

Final thought

The first hour of the inquiry session looked in detail at the difficulties presented to NHS providers. The distinguished panel shed light on the practicalities of integrating health services and systems to allow a greater standard of treatment and care. In particular, the discussion on ICSs highlighted an important structural change – the results of which are yet to be seen.

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