Building the system, interview with Terry Willows

The Good Governance Institute has a long affiliation with Sussex Integrated Care System, and has been supporting its development over the past year.

A few weeks ago, on the eve of the formal constitution of the system, we sat down with one of the people at the heart of this work, Sussex ICB’s new Chief of Staff and Corporate Affairs (and the CCGs’ Executive Director of Corporate Governance before that), Terry Willows, to talk about the development journey and aspirations for the future.

Daniel Taylor: Building complex systems takes time. What has the experience been like in Sussex?

Terry Willows: Back in 2017-18, when sustainability and transformation plans were first required from systems, ours was one of the lowest rated in the country. We had real challenges around relationships and around governance. We had NHS England wanting our seven CCGs to have governance reviews and most of them placed in legal directions, and we had trusts in special measures.

Over the past three or four years we’ve put an emphasis on collaborative leadership and focused on relationships across the system, both between organisations, but also the interpersonal relationships between system leaders. That gave us a really strong foundation for, we think, a pretty innovative and far-reaching approach to how we wanted our system governance to work when the announcements were made about ICSs becoming statutory.

Nothing we've achieved in the past few years could have happened without the foundation of these relationships across the system. The pandemic was quite helpful in that regard; it pushed a lot of systems to work in a very different way together.

Daniel Taylor: What challenges did you have to navigate in developing those relationships? How important was it to create a shared language, culture and purpose?

Terry Willows: The biggest challenge, which will be a common one for ICSs across England, was organisational silo-based thinking. The way the system works now, there’s much more integration across providers and commissioners. Just two years ago the picture was totally fragmented.

To address this, we worked in an alliance way with three CCGs within the mid-corridor of Sussex and that expanded eventually to, to include all of the CCGs in Sussex, and then we consolidated that through statutory mergers of the CCGs. Then, to the same timeline, there's been a bit of consolidation in the provider landscape - our biggest provider, which I think is now the fifth biggest acute trust in the country, University Hospitals Sussex, brought together the old Brighton and Sussex University Hospitals Trust and Western Sussex Foundation Hospitals.

That was the start of a consolidation and a much better working relationship across the whole system. Relationships have developed through and as a result of those consolidations. At the same time, I think the mindset of existing leaders has slowly been changing and adapting to these new ways of working and the greater emphasis on collaboration and system thinking. Alongside that we’ve got new leaders coming into our system who are very much of this mindset and bringing the skills and experience needed for integrated care to really work.

Daniel Taylor: Do you get a sense though that there's a genuine feeling that actually, this integrated care model will provide a platform for transforming population health and wellbeing? That it can deliver meaningful outcomes around the four key aims?

Terry Willows: There’s certainly more optimism than scepticism. For me, the really big opportunity that we've got through this new statutory framework is the ability to really embed and build-in that integration with local authorities in particular. And also the partners who work in the space where local authorities and the NHS come together, like the voluntary and community sector.

Our conversations with partners, particularly local authorities, have been evolving and maturing around how we can realise the potential of this integration. I think they are genuinely excited, both at member and officer level, about the new system, and how we can work together to really tackle some of those really deeply entrenched public health problems that we've got across our communities.

At the board away session for the new integrated care board recently there was a real recognition there that we've got a powerful coming together of NHS leadership and local authority leadership, we've got the levers now. If we can develop a strategy which makes sense at a system level, but more importantly works at place level, then you've got a lot of power and all the right players to really deliver for our communities.

Daniel Taylor: That’s great to hear those relationships are going to be key. In this developmental journey to now, is there one particular thing that stands out to you as being something you're particularly proud of, or one aspect of what you've done that was a significant achievement?

Terry Willows: We’ve invested a huge amount of time in bringing people with us. That starts at the top with Stephen, our integrated care board chair, reaching out and meeting with all key system partners and stakeholders and engaging them at every stage of the process, making them feel part of the system design. Governance nerds like me love a governance diagram and a structure chart - how this reports to this and who's accountable to who. But actually the power of that is when you can bring that to a room and really engage and enthuse people with it, that conversation of ‘oh, that's how it's going to work’, or actually ‘oh, yeah, it looks good on paper, but have you thought about X or Y?’

And that helps me, as the governance lead for the system, to think actually do you know what, we haven't gotten that quite right. Let's go back to the drawing board a bit and just think that one through.

So, I think that's the thing we've done really, really well, Are you going to ask us what we've not done so well in a minute?

Daniel Taylor: I wasn’t, at least not straight away but now you've intrigued me. It would be interesting to hear if there were any things you felt didn’t go quite so well, or you think were strong lessons you've learned in the process. Hindsight is a wonderful thing, right - but if you could go back are there any things you'd approach differently? Or, was it the case that it was better to have learned some hard lessons on the way because in those you forge relationships, and you get other things out of that experience sometimes?

Terry Willows: Yeah, you do. I think if I was doing this again, whilst we invested a huge amount of time in collaboration and collective design with system leaders, if I look at the staff that I sit and work with here in the CCGs who are about to become the engine room of the integrated care board, have we done enough with them? Do they really understand what's going on? What the changes are going to be, how their roles are going to change over the coming years as the ICB and the system develops. I think if I went back, I'd want to think about that, because ultimately, for me, governance is about how everyone in the organisation understands their role in decision-making. It’s about helping everyone to understand how they contribute to that decision-making and the pathways that they need to follow, and that those pathways are simple, pragmatic, don't tie people up in bureaucracy, allow people to get on with their day jobs, but understand the train tracks, for want of a better word, that they need to work within.

So, I think there's definitely something in that space. Of course, we could have done things in different orders and got a bit further ahead on certain parts of the design. Right at this point in time, it’s incredibly tense, because there's so much to do over the next couple of weeks. So, could we have front loaded a bit of that? Maybe, but then we wouldn't have had time to do all the engagement and the bringing people with us.

Daniel Taylor: Yeah it’s an interesting one, isn't it, because relationships develop at the speed of trust, and trust is a difficult thing to build. But once you’ve got it, so long as you don't lose it, and you've obviously got to protect it, but having strong relationships and having trust, particularly at the senior leadership level, that's going to pay dividends and speed up things for years, as long as it's maintained. I think a lot of directors of corporate affairs/ engagement in systems would make the same point about spending more time talking to staff about what it all means to them. There’s still time for that though!

On a related note, were the guiding principles and important principles that you had in mind when you were designing the governance for the system. You talked about engagement being key. You also mentioned the simplicity.

Terry Willows: It had to feel different, because integrated care boards are different, and I think the worst thing we could have done is carry over the ways of working or the board structure that sat at CCGs or in our providers. The ICB and the integrated care partnership, we're calling it the Assembly and Sussex, are very different entities to any of those partnership forums that have supported our ICS in the past. We could have just had a finance committee, and a quality committee, which would have been easier, actually, from my perspective, because that's a simple transfer of functions. But actually, when you think about what the ICS is about, it doesn’t really get us close to what we're trying to achieve through ICS working. If you think about those four core purposes, the health inequalities, the financial sustainability, the quality of services, etc., our Chair was very clear that we wanted a committee structure, which very much reflected that. We've got committees which look at population outcomes, we've got a committee which looks at patient experience, we've got a committee which looks at system productivity. For us, they're the three key areas where actually, if you can drive system innovation and collaboration around those three areas, then you will start to achieve what we're trying to achieve, what the core ambitions should be of every ICS.

Another driving principle was that we wanted to cut out duplication. There's a huge complexity of meetings which have found their way into the ways of working across a system; a programme board for this, or an oversight group for that. We've gone through a deliberate process of assessing the validity of all of those meetings and working out how they fit into our new system governance model, and cutting the unnecessary duplication to give people time back to get on with the job.

Daniel Taylor: I love the idea of committee structure driven by those four key pillars of purpose as it were. That's excellent. Let’s talk about place…

Terry Willows: We’ve got three very clear places built around our local authority footprints. I think probably the biggest realisation that I've come to through this processis that we've been focused on the big pan-system stuff, whereas place is really where we are going to improve outcomes and address health inequalities, transform services, and reach some degree of financial sustainability.

Of course, there will be things which we’ll need to do at system level, which are the things which you can't do at place. So, education and training, tackling the big workforce challenges, digital, all those kinds of things, which are big ticket, pan-system things. But actually, if we can re-orientate everyone around places, that is where we're really going to have the biggest impact, and then I think we will go some way to address some of the challenges we've got in our system.

Daniel Taylor: Your MOU was praised by NHS England as being the best in region. Were there any bits of feedback from NHSE or learning that you think would be helpful to other systems?

Terry Willows: I’m not just saying this because you work for GGI but I think we couldn’t have got to where we got to on that MOU without GGI’s support.

When you're preparing something like that, which really involves a whole host of input from leadership, different partners, etc., having someone who's external to the system, who can be a bit of an honest broker in some of those conversations, that really helped us. GGI held the pen but also helped synthesise and make sense of some of the content and pushed back a bit when it wasn't consistent with our overarching system narrative.

Daniel Taylor: So, from 1st July onwards, what are you going to do to keep that momentum and make sure you keep building on the good work and the progress?

Terry Willows: If we’re confident about one thing, it’s that we haven't got this right. We know we're going to have to adjust the model and the governance approach etc. Because we won't have got it right; it's just impossible unless we’re like clairvoyants that can see into the future. So, that constant reappraisal throughout the course of the year is absolutely something we're focused on. We have built in a requirement for a review of our constitution and governance arrangements at the end of the year, because we feel we need to formally plot the point for that evaluation and honest reflection.

Then we will do a piece also on reviewing the effectiveness of the board as well alongside that, so making sure that the governance is established in the right way, and that we've got the right individuals and the right capacity and capability in there to really lead the system.

So, in short, we've already planned our review points.