Delivering today and building a better tomorrow

Graham Urwin is CEO of the integrated care board for Cheshire and Merseyside Health and Care Partnership, which comprises 19 trusts serving 2.7 million people living in nine local authorities ranging in size from Liverpool (home to about half a million people) to Halton (where there are 130,000). GGI spoke to Graham about some of the implementation challenges faced by one of the country’s biggest ICSs.

Since joining the NHS in 1989 as an accountant, Graham has experienced numerous approaches to public health management. His experience gives him an invaluable big-picture perspective on the drivers behind the latest reforms – and the many that preceded them.

He says: “Any population will always be capable of consuming more healthcare than it or the government that represents it will ever be able to pay for. What we are doing at any given point is trying to spot where we are on that curve. Do you address the fact that demand exceeds supply by additional investment? Or do you address it by trying to get the service to work in a more efficient and effective way?

“We had unprecedented levels of investment in the NHS through the late 90s and most of the noughties. We then had a period of sustained austerity, which drove a certain amount of efficiency. But that was transactional efficiency. There's a genuine recognition now that we have to get into the space of some transformational efficiency that will come from how we are able to work together.

“We need organisations not to compete with one another, and we need to simplify our shared relationship with a patient or a citizen and see if we can do better. So, when we talk about our different places – whether we’re talking about Halton, St Helen's, Warrington, Sefton, or any of the other places in Cheshire and Merseyside – how do we use the public sector pound in the most effective way, so that we do not simply transfer costs from one part of a system to another.

The right model

Graham believes that integrated care offers a good platform on which to build improvement. He says: “This is the right model to create the right circumstances for people to sort it out locally. The model is not in itself overly prescriptive from the centre. I think it is intellectually the right model. We are better taking a view of one public pound, we are better taking a view of how commonly interested, players work together, and take out some of the unnecessary costs that are created in the system.

“We want to drive out some of the behaviours that we have seen that come about by single organisational priority. So, if we describe any optimum model of health and care, what you really come down to is the patient or a citizen at the heart of it, and then being able to access the right point at the right time.

“We don't do enough proactive care. We don't do enough risk stratification of our population and working with them in a proper preventative agenda. So, some patients present too late. And if they present too late, what might have been a simple intervention suddenly becomes a high-cost intervention.

“We clearly then have a challenge about when we want to discharge a patient from hospital, where do they go? Do they go back to their own home? Do they go back to their home with no support? Do they go back to their home with some form of domiciliary care support? Or do they go to another setting, intermediate care or care home? Again, at all of these handoff points, there can be tensions between health and social care. The ICB and its formal relationship with the nine local authorities creates an environment where we can be organisationally (and perhaps more importantly budgetary) agnostic to find better solutions. Increasingly, we are seeing mutual shared leadership and common interest, paying dividends in this area.”

Relationship building

Graham says relationships and trust will define the success of integrated care. He said: “You can't work in partnership unless you first have a relationship. So, a lot of our time has got to be dedicated to building that relationship and building trust.

“You can set out all of the rules you like, but it is behaviours that will define this, and it is how you then conduct yourselves when a behaviour from either within your own organisation of from a partner doesn't quite meet the standards which you would have hoped for.

“For me, you codify the relationship, you codify the behaviours that you would expect, but then you continually test them, and you continually test them by progressively doing more and more work together.

“One of the big problems we're having with our relationship with local government is the really difficult issue with funding. I think everybody would recognise that successive governments have squeezed the social care envelope tighter and tighter for more than a decade now. Initially this drove efficiency and transformational change , but over time some really hard choices are now having to be made .

And of course our business rules , or the perception of our business rules doesn’t always help . Within the NHS, when an individual becomes a CEO (Accountable officer) there is a statutory requirement for that person to balance their budget. But some time in the late 90s, the NHS moved its financial balance requirement to a rolling three-year average, unlike local government, who have to balance their books every year.

“Furthermore, the perception of people is that the NHS gets bailed out. Actually, if you set aside COVID, the NHS doesn't get bailed out, because the NHS has met its financial control total for as long as I can remember. But it hasn't necessarily met it down at every CCG level or every NHS trust level.

“So, our colleagues in local government have the perception that they work under a hard financial regime where they have no choice but to balance their books, but their perception of the NHS is they think the NHS gets bailed out by the centre.

“I have some sympathy for that. But if we are going to make integrated care a success, we need to think about the shared governance that exists between us and local government.”

Integrated care priorities

Graham sets out his four key priorities as we make the transition into integrated care: “The first one will always be delivering today. There is somebody right now waiting too long for an ambulance, there is somebody who this morning waited too long on the phone to get through and make a GP appointment. There is somebody waiting too long in an A&E department.

“My second priority is recovering from the pandemic, and it’s really important to say that this isn't just about physical health, it’s about mental health as well.

“My third priority is building these systems of collaboration and integration.

“And my fourth priority is tackling the wider determinants of health. Now, there's much in which we have common ground here. But people would say to you that the wider determinants of health aren't things that necessarily the NHS will do. The biggest things that will make a difference in that space, is better education, better employment prospects, better income coming into people's households, tackling poverty, good quality housing, inclusivity.

“If we do better at all of those things, demand on NHS services will go down, people will live longer lives, people will live healthier lives.”

But what about the inevitable friction between the first and fourth of these priorities? That’s a challenge system leaders must rise to, says Graham. “Any leader must be aware that the urgent crowds out the important, and you have to find a way of making sure that you dedicate sufficient management time and the discretionary resource that is available to you to invest in the things that are going to make a difference upstream.

“That's why Cheshire and Merseyside has signed up to being a Marmot community, and that's why when we publish our five-year plan towards the end of this year, we will have embedded within it all of the recommendations from the Marmot Report that has just been produced for Cheshire and Merseyside. By making those things part of our five-year strategy, we have committed to having a balance between the delivering today and making a difference for the future.”

Bright future

The scale of these challenges underlines just how hard it’s going to be to make a success of integrated care, especially in an area as large and complex as Cheshire and Merseyside, but Graham remains optimistic. He says: “Everybody wants this to be a success. There are some points in our history, where maybe we've talked ourselves down, or we have allowed bigger issues where people have wanted to challenge government policy to be conflated with local issues, when they are really not local issues. Since I've been in post, I have found nothing other than both an intellectual curiosity about how we're going to do this, but an absolute desire to work in that partnership, and make things better.”