CHAPTER 1

THE NEW DIGITAL IMPERATIVE

New perspectives and partnerships

Do you anticipate a significant change in the needs of patients within the next five years?

YES
NO
UNSURE

IN THIS CHAPTER

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INTERVIEW WITH DEBBIE BARNES - CHIEF EXECUTIVE, LINCOLNSHIRE COUNTY COUNCIL

INTERVIEW WITH HELEN BROWN - CHIEF EXECUTIVE, WHITTINGTON HEALTH NHS TRUST

To meet these changing needs, 83% are optimistic that health organisations will have the flexibility to pivot and adapt, while 86% think that furthering collaborative partnerships is a priority in tackling future patient needs.

In the UK, four in five (82%) of these leaders agree that the arrival of the ICS has seen a change in the culture of planning and delivery in healthcare. From those leaders we’ve spoken with, most welcome the change as providing more connected ways of delivering care, but recognise the challenges faced in aligning multiple organisations together behind a collective objective.

The introduction of the ICS provides a unique opportunity for organisations across the system to collaborate and place the patient at the centre of their focus, starting from prevention.

These leaders have told us that health promotion and education is an area that should be a priority. This focus helps to alleviate cost pressures and workforce challenges that dominate the public sector.

Do you feel that your organisation can make all the changes it needs to adapt to the changing healthcare ecosystem?

Definitely
Somewhat
Unlikely
No

Operational transformation in integrated care

The implementation of integrated care systems (ICSs) has driven significant changes in how healthcare is structured and commissioned within the NHS. The ICS structure serves to further collaborate across local and regional health services through more partnership working, aiming to provide optimised patient outcomes and more efficient healthcare.

Healthcare leaders across the public sector anticipate that collaborative system working will provide numerous benefits and opportunities, such as those from tailoring healthcare to local communities, creating space for innovation and developing longer-term strategies.

We spoke with a variety of public sector healthcare leaders who are committed to creating a more efficient and forward-thinking health system.

For the remainder of this chapter, this audience will be referred to as 'leaders'.

Our research has shown that these leaders anticipate a significant change in the needs of patients within the next five years.

“Integrating health, social care and education is a great opportunity to drive forward innovation and relieve pressures on local healthcare services.”

Debbie Barnes
Chief Executive,
Lincolnshire County Council

Debbie Barnes has been Chief Executive of Lincolnshire County Council since 2019, having worked at the authority since 2006, including in roles such as Director of Children Services. During this interview, she describes the opportunities for improving health services, the challenges between local and national leaders, and her vision for the future of local health services.

The benefits of integration
ICSs provide a unique opportunity to build relationships across health and care commissioners and providers, particularly between local authorities and health services, such as Lincolnshire County Council and Lincolnshire Integrated Care Board (ICB). Barnes’ initial impressions of the integrated structure is supportive, describing “integrating health and social care bodies as an opportunity to drive forward innovation, with the focus on prioritising the health of

the whole population, tackling health inequalities not just focusing on those who need to access acute hospital settings.” In Lincolnshire, Barnes believes the high levels of integration and coterminous systems are a huge benefit to integrated health and social care, with pre-existing relationships and joint commissioning through pooled budgets ultimately enabling better outcomes in provision.

National impositions and local frustrations

At the same time, there are ongoing tensions between how national and local priorities are simultaneously met. For example, the priorities of NHS Trusts and commissioners tend to be driven by nationally aligned KPIs, covering areas such as hospital beds, ambulance waiting time requirements and GP appointments. This national focus tends to be short-term, prioritising acute settings, which do not always align with the needs at local government or community level.

Debbie Barnes
Chief Executive,
Lincolnshire County Council

During challenging times for the NHS, such as winter, focus can switch to operational day-to-day urgencies rather than on longer-term priorities. In reality, while short term challenges will always arise, they shouldn’t derail long-term focusses. Another risk identified by Barnes is the duplication of strategies at both local and national levels.

Under its remit, Lincolnshire County Council created a ‘Lincolnshire Health and Wellbeing Strategy’, identifying the strategic priorities that the partnership is working on. However, under the new arrangements, there is now a requirement to develop an Integrated Care Partnership Strategy which has led to duplication. In addition, the ICB is also responding to the need set out by NHSE to create a ‘5-year NHS Joint Forward plan’ for Lincolnshire - this is expected to be complete by the end of June 2023.

This plan requires a focus on key strategic priorities at an ICS level for the Lincolnshire NHS system, defeating the positive drive for integration. According to Barnes, the creation of these three similar strategies pulls them in various directions and adds bureaucracy. This means they “spend much needed capacity to write strategies rather than getting on and doing the day job of supporting communities and tackling health inequality.”

Debbie Barnes
Chief Executive,
Lincolnshire County Council

Barnes also raises concerns about the needs of children and young people who, in her view, are not given the prominence that she would advocate for within the ICS. She sees the impact and needs of children “too often forgotten in terms of the integrated care systems space”, with national KPIs focused predominantly on other populations and the acute sector. This lack of national focus “is a missed opportunity to drive integration across health, care and education, which would enable behaviour change and improve child health.”

Enabling individuals to improve their own health and
self-care

There are three areas of development which, according to Barnes, would alleviate pressures on the NHS and strengthen patient outcomes:

reforms to technology (including technology enabled care);
changing the nature of how community-based social and healthcare is delivered; and
empowerment of carers to allow for a greater patient and carer experience and enable more people to be independent, receiving care at home.

First, healthcare should move from ‘reactive’ to ‘proactive’, with increased encouragement to live healthier lives as opposed to accessible and available support for those who are ill. Improving health knowledge, awareness and health promotion services would encourage people to feel more confident in their own abilities to seek appropriate services or, where possible, a self-care solution, preventing people from getting ill in the first place.

Debbie Barnes
Chief Executive,
Lincolnshire County Council

Barnes also wants individuals and families to be empowered to play an active part in the care plan, as opposed to passive participants. She believes this can happen by an increased focus on technology.

If there was “a big increase in technology use, such as massive advances in sensors, remote health care monitoring and access to technology enabled care, this would help people to be able to stay at home and allow people to be discharged from hospitals sooner.”

Overall, Barnes’s view is that while the structures are in place for successful health and care integration, such as integrated care systems and local authority collaboration with NHS trusts, there remain some missed opportunities.

For example, considering links with children’s services and educational settings could encourage students to lead healthier lives and go on to prevent them from needing
acute care.

Shifting the public mindset around healthcare priorities to a greater focus on health promotion remains the main challenge. Right now, it focuses primarily on shorter waiting times, and much less on public health campaigns that could help create a system that is more resilient and sustainable for those who need it.

Many leaders recognise that changing approaches in organisations of the scale of the NHS will take time. When choosing which innovations to introduce to hospitals, the challenge is knowing where to make investment to achieve this.

What we want to avoid is it becoming a thousand flowers blooming. We want to introduce transformation that supports clinicians or employees and our patients in the best possible and most coherent way."

This mindset change must occur internally and externally to the NHS, with health care professionals (HCPs) adapting their models for delivering care to meet changing patient needs, while patients themselves take on a more active role in managing their own health.

The ICS, as a supportive structure that organises integrated care boards (ICBs), regional trusts, and local authorities, gives impetus to this through enabling a horizontal framework.

The ICS allows health organisations to pool together these resources. Increase resources, improved partnerships and flexible operating models are seen by leaders as the three factors most likely to have the largest impact on their services. In the UK, ICS implementation is already seeing success across collaborative partnerships with the resulting shift of focus onto strategising plans for future workforce retention.

What will have the most positive impact on the overall quality on your onganisation's service?

Increased resources
Improved partnerships
A more flexible operating model

Our research uncovered the positive impacts that increased resources, improved partnerships and flexible operating models can have on service quality, in turn optimising patient outcomes. Greater integration is creating shared strategic visions between organisations, leading to more focused and efficient healthcare service delivery that works for both staff and patients.

"Digital transformation should be approached, above all, from a patient experience perspective.”

Helen Brown
Chief Executive,
Whittington Health NHS Trust

With a career spanning over 30 years in the NHS, Helen Brown has gained experience across various areas - in both operational and strategy-focused roles. Reflecting on her current role leading Whittington Health, a North London-based NHS Trust, Helen discusses the challenges of implementing innovation and standardisation across the health service.

The need for system-wide solutions
Whittington Health is a smaller trust surrounded by much larger players, such as the University College London Hospital
and the Royal Free Hospital. It offers a broad range of services to patients in the North Central London catchment area, with strengths as a local integrated care provider rooted in its community. Brown explains that building on the strong, pre-existing clinical relationships across providers, Whittington are
now developing a more strategic corporate partnership

Helen Brown
Chief Executive,
Whittington Health NHS Trust

model as well. “The ICB is strong and there are some good programmes of work. We are the best performing ICB in the country on elective recovery, for instance, driven by significant collaboration across the system” - points out Brown. “But there needs to be more focus on improving community services and addressing the historic imbalance in resources between the inner and the outer parts of the sector.” Brown believes that the lack of time and attention being dedicated to community services is due to their negative framing. “It’s tempting to think about community services from the perspective of stemming demand for hospital care, rather than focusing on how we could improve the wellbeing and health outcomes for people living in the community.”

Brown adds that while the vertical integration in healthcare provision has many benefits, the need for a horizontal integration should not be ignored, and she hopes this will be only strengthened with the strategic focus of ICBs on place and population.

Digital transformation - from ad-hoc to strategic

Discussing the role of digital transformation, Brown notes that the priority for healthcare providers should be to identify the changes they already have the tools to implement. “There is huge potential in digital transformation, but we need to start with implementing what already exists, in a more robust way” - she says.

“COVID, of course, was an example of how virtual healthcare models can be set up almost overnight if the will is there. In my last Trust, a number of our respiratory physicians were clinically vulnerable, so they could not work hands on with patients. But they were able to rapidly set up a digitally enabled virtual ward that was hugely successful and helped establish a new mindset from clinicians about what is possible in digitally-enabled care.”

Helen Brown
Chief Executive,
Whittington Health NHS Trust

Brown explains that digital-related decision-making is often borne out of necessity, not strategy.” For example, issues with on-site car parking leading to a change in the care pathway and switch to a digital solution for urine testing” - she says. “Digital transformation should be approached, above all, from a patient experience perspective. There is so much cross learning opportunity for ICBs in terms of optimising virtual outpatient services, for example, but we need to spend more time and effort understanding what good really looks like from a patient perspective, and from a clinician perspective.”

Engineering change - a challenge of resource
Talking about the front-of-mind challenges from a leadership point of view, Brown highlights that the lack of investment in change management and business process redesign is a fundamental obstacle to effective service improvement.

“There is a narrative that we are overinvested and must reduce management costs. I actually think we are just invested in the wrong things at the moment. Strategic investment in junior, middle and senior management capability is crucial to being able to re-engineer and support change across the NHS.”

Brown notes that in clinical terms, the biggest objective is to ‘free up time to care’ and allow people to operate at the top of their licence. “Our system is not designed to make the best use of people’s skills. When those in management roles spend 90% of their time putting in paperwork for vacancy panels, filing staffing request forms and chasing through procurement, they will not have capacity to focus on anything value-added and developmental" - she explains.

Meaningful transformation, in Brown’s view, must start with streamlining those manual and dysfunctional processes.

"We have to increase efficiency throughout the unglamorous parts of our organisation. Otherwise, we will carry on doggy-paddling, instead of starting to do the strategic front crawl.”

While organisations now have the opportunity for greater collaboration, it’s now up to healthcare leaders to utilise new relationships and new opportunities for potential organisational benefits and for the health of those under their remit.

We have heard from leaders themselves, that ultimately how successful different ICBs are likely to be across the UK will be determined by the genuine strength of personal relationships between leaders within different organisations, motivated to find new ways of working together.

The future of health looks bright as new efficiencies are emerging across the provision of public sector healthcare. This transformation allows leaders and healthcare professionals to consider new solutions, streamline processes, pool resources, share expertise and build a more sustainable health system.