4 November 2022 – NED webinar – A strategy consultant’s perspective

This week’s session opened in conversation with Fenella McVey, principal consultant and director of innovation at GGI.

Fenella said: “If you know one ICB, you know one ICB… One notable thing is that the ICBs were all established, which is a feat in itself, especially given the circumstances over the last year. People really need to feel proud of that achievement. Now it’s all about development and we’re seeing ICBs growing into themselves and settling down. The issues they face are varied. For some it’s the non-execs who need support, for others it’s the execs. In others, it’s the partner members – really fractious relationships with local authorities or primary care partner members.

“In terms of what they’re prioritising, there the similarities are much closer. There’s an enormous amount of pressure around waiting lists and ambulance waiting times. Things like inequalities – ICBs are struggling to get the balance right between those immediate pressures and some of their long-term objectives around reducing inequalities and improving outcomes. It’s been hard for them to not be NHS-y – with these immediate priorities around waiting lists, it all feels very health-focused and that’s been called out by local authority partner members and others around the system, who say ‘this is supposed to be about population – let’s talk about population rather than patients.’

“A lot of ICBs are working through issues they were always going to have to work through. It takes a few meetings to establish a common understanding of what a committee is really focusing on and what the flow is at system and place level. And similarly, around an ICB boardroom to really get to know each other and trust each other and feel comfortable sharing. It just takes time.

“However, historically people have been very successful in organisations and now they’re in a system. Systems thinking is not embedded and is one of the biggest challenges and is one of the things that will trip people up the most – it’s interesting to see those systems that have prioritised that. It feels quite intangible in some ways but doing joint development, not just with the ICB but with system partners and recognising that this is going to be a multi-year journey to make people across all the organisations, down the different levels, think about partnering and getting early input from people, and co-creating, rather than being confined by the areas they’re used to, is one of the biggest challenges.

“System risk is often selected as the second or third section after the initial getting-to-know-you sessions. The appetite for risk seems to be changing as a result of the context. One trust CEO was saying about a particular scenario: ‘If you’d shown me this a year ago, I would have been right at the cautious end in terms of risk, but now the pressures on the system are so high and the current status is already so loaded with risk that my appetite is right out on seek because even doing something very different feels less risky than carrying on as we are now’.

“There’s been a real appetite to look overseas and at other sectors for how they might think about things differently. One example was the IKEA value-based pricing model as an example of frugal innovation. Right at the start of the process, before they even start to design a chair, IKEA knows it must look modern and streamlined and they know the most their customers can pay for the chair is £49. So they know the budget before they’ve even started to draw the first line of design. And they use that to start their planning rather than starting with need and then bumping up against budget.

“It’s also very difficult to be constrained by annual financial plans when some of the system aims will require 10 or 20 years of planning to achieve, so how can they create a thinking space in which they can plan for 10 years despite the annual budget cycle?

“It’s really striking for such a large sector with billion-pound organisations for there to be this much uncertainty. If you compare it to FTSE 100 companies, there are more things they have control over. However, it’s not unlike start-ups. Agile is already adopted in the NHS but that operating with constant uncertainty is a marked feature.

“Place is a really tricky level to operate at. Those who have made progress there have gone to a sub-place level, looking at neighbourhoods or even just a couple of streets. You can have streets right next to each other with a ten-year life expectancy difference, so you almost want to group streets by the types of challenge they face rather than geography.”

Also overheard during the session:

“Financial pressures has forced the NHS back to patients. There is also frustrations that we cannot control the Better Care Fund.”

“Systems thinking, as alluded to already, relies on maturity of relationships between partners.”

“Some NEDs have to be the consultant to the service because of managerial bounded rationality.”

“We need to deliver both CCG+ and system-wide assurance, irrespective of the title of the respective committee.”

“I agree on diversion of resources to make greater impact on the frontline, but this does require more buy-in beyond one visionary leader…that in itself is a challenge because too many people in the new entities are from the ‘old world’!”

These meetings are by invitation and are open to all NHS non-executives directors, chairs and associate non-executive directors of NHS providers. Others may attend by special invitation.

If you have any comments, questions or suggestions about these webinars, please contact: events@good-governance.org.uk