In advance of our January NHS Whispers webinar on ‘Healthcare, economics and society – unlocking NHS collaboration’, we received some really insightful questions from those who registered. Here we answer some of those we were unable to explore in full during the webinar.
The webinar saw Prof Phil Richardson (Chair and Chief Innovation Officer, Mtech Access) interview Michael Wood (Head of Health Economic Partnerships, NHS Confed) about the NHS’s social and economic potential. In December (2022), Michael had authored a report exploring the economics of healthcare and where broader strategic partnership working might lead system thinking in the NHS. The webinar is now available to watch on-demand here.
The prospect of Michael and Phil’s discussion inspired a wide variety of questions from our audience. This included leaders from Pharma and Medical Device companies, other Life Sciences innovators, and colleagues from across the NHS and the wider healthcare sector.
We were unable to explore all of these during the webinar itself, so Phil has penned answers to these here, with input from Michael.
Your questions on healthcare, economics and society
1) Describe what an industry partnership would look like, how it works, and how it's developed, and highlight good examples.
There are many successful industry partnerships with health systems. They are almost always focused on the need of the health system and not the product or service of the organisation.
The partnership provides industry with an opportunity to experience the pressures and challenges in a system, to help develop strategy and better allocate resources. The system benefits from expertise and innovation.
The partnerships are built the same way any partnership is built: starting with background research, understanding internal capability and capacity, looking for aligned purpose, investing time and energy in getting to know the system and agreeing areas of mutual interest.
Examples we have seen would include:
- A major cyber security organisation helping develop AI knowledge and capability with an Integrated Care Board (ICB)
- A Pharma company improving the quality of programme and project delivery for an Integrated Care System (ICS)
- A Small Medium Enterprise (SME) Medtech company training Healthcare Professionals (HCPs)
- A Biotech company helping a system develop data science skills
A deep understanding of the landscape is needed, and a change in both measures and value proposition development is essential. Expert help such as that provided by Mtech Access can both accelerate the process and improve the quality of the approach.
2) What will the role of Place based partnerships be versus healthcare boards in funding decisions?
The intent is for ICBs to allocate funding and focus central resources through the ICB plan. This will include delegating funding to place and neighbourhood. The overall approach will be determined through subsidiarity, with only the commissioning done where it makes sense for the local system.
Going forward this will include dentistry, ophthalmology and pharmacy, traditionally commissioned directly through Regions.
Specialist commissioning is not yet fully resolved, although the intent is to delegate that to ICBs where the scale is still effective. Delegated commissioning will be coupled with delegated performance responsibility, which includes outcomes for the local population.
The Integrated Care Partnership strategy will be key to this approach as it determines the strategy for both the NHS and local authorities.
The Voluntary, Community and Social Enterprise (VCSE) sector will play a larger role in both strategy development and delivery. There is also an expectation that local communities will be more closely embedded in the design, production and delivery of services, which will include self-service.
3) What are the top 3 priorities that can realistically be addressed?
The health and care system is complex. It cannot be simplified into a list of priorities as there are day-to-day pressures on service delivery. The challenges can be seen when an emergency, such as the Covid pandemic, took priority over elective care.
To help maintain balance, the NHS sets out areas for priority focus and provides guidance on the performance and productivity of organisations and services.
4) What are NHS leaders looking for from Pharma?
It’s worth reframing this question. The NHS isn’t looking for anything from Pharma. It is looking for solutions to complex problems.
If asked directly the question would result in and answer repeating the same phrases: lower costs, fewer similar products, more transparent access to data.
By taking a solutions-focus the question changes the dynamic from transactional to the opportunity for a strategic partnership. I would avoid asking “How can we help?”.
5) How does the NHS seek to overcome the long diagnostic waiting times for patients awaiting genomic diagnostic results?
Rapid access to diagnostic results, including genomics, is a continual challenge. The root cause lies in workforce availability, access to the diagnostic service, and ability to follow through into a clinical pathway for the patient.
Recent investment in Community Diagnostic Centres (including several located in high street settings, not hospitals) starts to address the issue. As does the roll out of @Home services.
There is a real opportunity to help solve the problems in the diagnostic space that brings HCPs, communities, diagnostic services and downstream pathways together.
6) Should the NHS focus less on financial resources and accountability, and more on social and environmental resources?
As the NHS budget is agreed with Treasury there is always going to be a need to focus on the financial position. That said, there is clear recognition that there is a key role to play in economic and social development. That is why the fourth purpose of an ICS is economic and social development. By setting out the Net Zero objective the NHS is already challenging other organisations, both commercial and public sectors, to do more.
7) How can our system leaders do better at elevating, including recognising and valuing, social care providers and the new energy they can bring?
There has long been recognition that social care providers bring not only energy but a fresh perspective on the challenges in systems.
In my experience in Dorset, the local authority social care teams were engaged from the start of system working back in 2014 and had worked with the NHS organisations in a programme called Better Together for a number of years prior. More recently, organisations that covered home care and domiciliary care, as well as social housing, education and end of life care providers, have been more actively involved.
8) How will culture/ways of working be supported to develop and evolve the integrated care agenda?
Supporting cultural alignment and integrated ways of working is complex. Particularly when the systems are comprised of multiple NHS organisations, multiple local authorities, the VSCE sector, patient groups, carers, other public sector organisations such as Police and Fire as well as private providers of both clinical, rehab and domiciliary care.
Each organisation is likely to be a sum of its micro-cultures and to be dealing with their own changing priorities and complex problems. Big steps, such as aligning behind a case for change, focusing on a shared purpose, recognising the strengths and weaknesses and being clear on resources and capabilities, are all essential components to drive the behaviours needed to support values and culture. They are also key to unlocking the imagination and empowerment which, in turn, will enable new ways of working.
Deep entrenchment of traditional wisdom, protection of turf and antiquated measures will hamper efforts. Trusted leadership, a passion for doing the right thing and being kind are the qualities we need to nurture and support.
Remember that integration is only a means to an end. It is simply the way resources get organised to deliver care. Integration, by itself, will not change anything.
9) What are the perceived biggest challenges with ICSs collaborating and delivering on their objectives?
The new strategy is different. It uses many of the same phrases and words, but it is different. Clinical Commissioning Groups (CCGs) were never in a position to deliver in the way that ICSs will be able to. CCGs had influence and persuasion but little in the way of levers for change. Achieving what they did, as facilitators in a system designed for conflict and competition, was phenomenal. Particularly given the way policy and isolated organisational structures created a disconnected health and care landscape.
The new strategy is different, the rules of the game have changed and the power is transitioning out of the weakening grasp of a few into the conscious community of many. It’s not a new front cover, it is a fundamental rewiring of the many parts. As well as the more obvious areas such as decision making, commissioning, operational performance, clinical models, integration, digital, safety, inequalities and population health, there are some fundamental shifts needed in what people think is already working.
For example, relationships have been formed based on the old way of trading. Such relationships were often transactional and based on a buyer-supplier partnership. Collaboration often played out in a ‘we are in the same meeting’ mentality, with a collection of interested parties, rather than a single team with a single purpose.
We need trained collaborators the way the Police have trained negotiators. We need to use the technology that is on everyone’s system to drive networks of like-minded people to own and drive change. Collaboration is a way of working. Solving how to do that whilst ramping up the transactions with an exhausted workforce, a feeling of managing relentless pressure and crumbling single points of failure – that’s the biggest challenge.
10) Health and economic development are truly factors in long-term health outcomes, but is the funding to deliver this just a dream?
The funding is the funding. The question is – how do we decide how to allocate funding? Michael Marmot has long advocated that the overall health of the population will improve through addressing the wider determinants of care.
Directors of Public Health and clinical practitioners such as General Practitioners (GPs), community nurses, local pharmacists and therapists, have long advocated for a shift of funding to community, where approximately 95% of care delivery happens.
However, we have an acute model that consumes approximately two thirds of the available funding. An evaluation approach to decision making, coupled with intelligent integration design and the headroom to do strategic and critical thinking will contribute to moving towards the answer. There needs to be a shift from organisation and professional viewpoints to people and community viewpoints with models of care underpinned by well thought-through operating models and risk assessed scenarios. It’s all about choice.
11) How do we obtain a full, real-time copy of our individual personal data that the NHS holds for each of us?
Information is held in a range of places, from paper-based records in certain hospitals to digital information in primary care. Work is ongoing to bring all the information together so that it can be used to provide better care.
At this time, the best source of available information is through the NHS app, which is available free of charge.
12) How can "prevention" with children's mental health ever be effective/find its place in the split between education/health/social services?
The ICSs, which became statutory in July 2022, place a mandate on public sector organisations to collaborate at place and in neighbourhoods. This includes creating an integrated approach to children’s services, prevention, and mental health.
For each Integrated Care System the Integrated Care Partnership (ICP) and ICB are required to create cohesive plans. Currently the work is managed locally through Health and Wellbeing Boards and public assurance is provided through Health Scrutiny Committees in local councils.
There is also an independent health assurance organisation called Healthwatch, which represents the patient’s interest.
13) How are the ways in which HCPs prefer to interact with industry evolving?
New cross-functional teams are emerging in systems to help drive collaboration. These teams are typically issue-focused, working on either a challenging problem or an identified opportunity. Ideally, industry needs to mimic this approach. It’s important to recognise that the teams are wider than HCPs.
14) What are optimal pathways for NHS adoption of novel precision health technologies?
I am not sure it is a pathway. There are many mechanisms that exist today to provide access for new and emerging technologies. These include:
- Academic Health Science Networks (AHSNs)
- Accelerated Access Collaborative (ACC)
- National Institute for Health and Care Research (NIHR)
- Clinical groups and clinical partnerships
- Innovation academies
- Digital transformation forums
Understandably with a complex innovation ecosystem, which isn’t mature enough to work in an integrated way, there are going to be conscious and subconscious blocks to progress. It isn’t a brilliant experience for everyone both inside the NHS and for organisations who have a value proposition that feels thwarted by identifiable and unidentifiable blocks. Focused work by the NHS at a national level is aimed at simplifying both market access and adoption.
Considered experiments, robust business cases, evaluated value propositions and meaningful and thoughtful engagement all help. Without the appropriate approach many organisations struggle to get to market in the desired timeframe. New routes and systems are emerging. For example, the National Institute for Health and Care Excellence’s (NICE’s) Medical Technologies Evaluation Programme (MTEP) is a relatively new route that is enabling some products to gain a formal recommendation (though not a funding mandate). Today, access to health systems is fragmented with multiple stakeholders and (short- and longer-term) funding options, but with the right evidence and communication approach, market access can be optimised.
15) What is the best way to access a partnership with the NHS when developing music and arts therapy?
Advocacy from patients, patient groups and connecting with the patient engagement leads is a good way of doing this. There are a few NHS arts leads in some NHS organisations, and a few directors of transformation will have arts and culture as one of their priorities. There are also organisations such as the Bournemouth Symphony Orchestra and the Lighthouse Theatre at Poole who have active health and music programmes for dementia.
There are organisations or umbrella bodies supporting initiatives like this, such as the National Centre for Creative Health.
16) How do we leverage the spending power of NHS, LOCAL GOV. and UK GOV. to achieve better outcomes for the poorest in our society?
By focusing on the evidence and making evidence-based decisions. The approach taken by Dorset ICS through the Dorset Intelligence and Insight Service is an example. NHS London is also making progress in this area with their pan-London social value tool. This should increasingly be a common agenda for a more integrated system.
17) How high is the likelihood of inequalities in healthcare arising due to new the ICS structure? And how do we tackle this?
All health system designs create a bias. ICBs and ICPs are at the heart of the ICS structure, and it is clear that their mandate is to tackle health inequalities. As each system is starting from a different point, the priorities and resource allocation will need to balance the strategic need and the local pressures. Each system will have a way to assess inequalities and put in mitigations not to create new inequalities due to their actions. Intelligent, evidence-based decisions that are scrutinised will both improve the approach and minimise detrimental impacts. Delivering high-quality change is the other determining factor.
18) What do you see as the greatest enabler to move the NHS's data sources to actionable change to address the key challenges?
Accessing rather than moving data sources is key. Setting out intelligent research questions needs to be done before diving into the ‘lake’ of data that exists.
This is important because there are elements of data that have not been captured and are essential to intelligent decision making. Just because the data exists and there is a motivation to put it all together does not necessarily equate to getting better answers.
19) How can companies integrate their existing social and economic initiatives into the NHS systems?
This is a great question. Look for an alignment of purpose to help identify those systems that closely match your organisation’s strategy.
During 2023, systems will be publishing their Annual Operating Plans and setting out their ambitions for the longer term. It is likely that the people who would be interested in a wider discussion about economic and social development are a mixture of NHS, local authority and VCSE. Devolution is an important agenda here in aligning civic priorities that align public and private work.
Think about how you could present your initiatives as a value proposition or value dossier. Understanding the local system will help, as will an up-to-date stakeholder analysis. These are all things Mtech Access can help you with – drop us a note if you’d like to explore this further.
20) There remains wide variation in moving to value-based procurement; is this truly a focus, to deliver efficiency and improve care?
I am not sure that value-based procurement is about efficiency. There are clearly cost envelopes for procurement of products and services, and commissioning had traditionally balanced the need with the optimal procurement that delivers the best value for patients and the services.
I believe there will be a reinvention of commissioning as the budget and authority is delegated to provider collaboratives and Place.
21) What is the biggest driver of prioritisation right now?
Operational pressures and the legacy effect from the Covid pandemic are the biggest drivers of priorities today.
It’s better to think about what is getting leadership attention as it is easy to get distracted by a published list of ambitions when in reality all the attention is on the operational challenges.
22) Will we see a return to PBMA?
I am not sure how well commissioning teams currently use Programme Budgeting and Marginal Analysis (PBMA). This approach predates CCGs and now ICBs. The types of question used in the PBMA model, however, are considered. Newly appointed Chief Commissioning Officers, or equivalent, will have a keen focus on this area.
23) What do the stakeholders to innovation and transformation need to see in plans, to make them want to invest in service change?
They need to see solutions that will deliver their objectives. Solutions are not products. They are the composite of skills, methods, tools, interventions, governance and resources. They will always be imagined and delivered by more than one organisation and they are likely to have a heavy digital component. The digital part is not IT.
24) What are the quick wins for ICSs to influence economic and social development, and what are the most impactful long-term wins?
Quick wins in this case are not easy to do. Indeed, if by a ‘quick win’ you mean something that is quick and easy to do, then there aren’t any quick wins. Too many of the changes needed to make an effect are interrelated.
Having said that, there are interventions that could start to make a difference. For example, increasing funding into the VCSE sector – here, a small amount makes a big difference in communities. Changing behaviours around exercise, such as Park Run, makes a measurable difference. Supermarkets moving health foods closer to the impulse purchase sections of the store helps. Changing social habits around alcohol, processed foods, exercise, mindfulness, takeaways, stress and mental health all help. Thriving communities, better employment, opportunities to prosper as a person and family helps. Access to green space, arts and culture and music all have long-term benefits.
Overall, the shift from a medical model in an acute setting to a community model at home is the only way to create a sustainable approach to economic and social development.
A key message from the NHS Confed report is that ICSs need to join existing conversations, rather than always trying to start new ones. That’s how we achieve quicker wins and, more importantly, build trust for future change.