by Merron Simpson, CEO of The Health Creation Alliance (THCA)
I recently attended a most extraordinary day at NHS Confederation ICS Network Conference, Learning Together, on 28 November 2023. I can honestly say I’ve never been to a mainstream NHS event quite like it; congratulations to NHS Confed for bringing together such an interesting series of sessions with so much dynamism.
Transformation is a many-headed beast which is perhaps why there seemed to be so many cross-rhythms going on… on the face of it diametrically opposing views but more likely creative tensions; certainly a common thread throughout. A sign, I suspect, of an NHS on the cusp of major transformation.
Each ICS had its own way of conceptualising the journey they’ve embarked on, with an infographic to illustrate this, and there were plenty of brilliant examples, diverse perspectives, deep experiences and sober reflections.
Cost of living crisis
Drawing on a set of facts I suspect most delegates felt they could rely on, Torsten Bell (CEO, Resolution Foundation) set out the realities of life in the UK in the recent past and imminent future in a session on ‘ICS role in the cost-of-living crisis’: 20 years of low growth/degrowth combined with rising inequality since the 1980s has meant that poor people have got a lot poorer with consequences for the public’s health. These are things the NHS can never solve; that will take a radical change in economic and social policy, and more.
Building constructive relationships
Matthew Taylor (CEO, NHS Confed) was more upbeat about what could be done when partners relate differently to each other. He also urged the NHS to “get into stopping things that aren’t very effective”; one ICB Chair stressed that ”this is the only way… we have to keep going… we are all part of one big ecosystem”. A Citizens Advice Chair made an impassioned interjection asking why ICSs are not focussing on what ‘good services’ looks like (from the perspective of those using them). The importance of ‘strategic alignment’ (a Public Health lead on Housing) emerged as a key route to recognising the commonality of local partner ambitions and coalescing them around common aims. Different sectors’ use of language, such as ‘prevention’ (is that clinical prevention or wider-determinants prevention?), emerged as an impediment if we don’t treat each other with respect and there was an appeal from somewhere (perhaps several places) to ‘invest in relationships’. All familiar territory for The Health Creation Alliance (THCA).
Primary care transformation
Given the relative under-investment in primary care over the last few decades, especially practices in the most underserved geographies, this session focused on the recent progress made to bring a fragmented, undervalued sector together, the relative benefits of the partnership vs salaried GP model and the difference the Additional Roles Reimbursement Scheme is making in connecting general practice with communities. There remains a strategic gap between primary care and other local partners who have significant contact with patients, something that The Health Creation Alliance picked up in its 2021 publication: Primary Care Networks and place-based working to address health inequalities; a partners’ perspective.
Tackling structural racism and discrimination
There was a plea for ICSs to create a culture of a profound sense of belonging and through rights-based, humane, anti-racist and anti-discriminatory approaches; a ‘new social contract’ of doing with, rather than doing to, communities. And Dr Habib Naqvi, CEO, NHS Race and Health Observatory challenged ICSs to look at the ´causes of the causes´ of ‘immoral, wrong and avoidable’ inequalities; they will need to do that if they are going to stand a chance of resolving them.
The ’evidence’ question
I was struck by the contrasting views of speakers around the role of evidence in decision-making. Here are a few of them as I recall them (paraphrased of course):
- “Can ICSs please ‘get over’ the requirement for an evidence-base”. (a local government view)
- “We need more evidence that community development is working”. (an academic view)
- “We need a big list of evidenced things that work from the centre”. (an ICB Chair view)
- “Don’t just go to the centre, there is a lot of evidence from many local organisations to draw on”. (and academic view).
Perhaps it should not have surprised me as much as it did; Health-professionals-attitudes-to-evidence-and-the-influence-it-has-on-decision-making is something the THCA explored a number of years ago for the National Housing Federation and found similar divergence.
Putting people first
The last session invoked the complexity as well as the unlimited energy and power of community (the people that is, not community trusts!) in contrast to the preferred conformity of most services and systems. Both ‘lived experience’ speakers made a compelling case for putting people first and then shaping services that create the conditions for them to live well with them. Is this not, after all, what the transformation is all about?
At THCA we have always known that every system needs to go through its own process of relationship-building; with communities, with other local partners and importantly, recognising the power of the connections that already exist between community members and between communities and other local partners outside the NHS. The experience of one CEO of a system committed to doing this is the revelation that what matters to communities, and what will make them able to live well, is not the same as what the data would lead senior leaders to; it is much more surprising and could never have been imagined without a conversation. Recognising the limitations of formal data and going where the energy is, means they can really start to address the causes of the causes of inequality that leads to poor health and do this with (not to) communities.
Complexity and coherence
People and communities are complex, and complex systems require an iterative approach. This is difficult territory for the NHS.
Some leaders are comfortable stepping into this space than others: “You have to do everything, all the time, all at once” (an ICS CEO). Others are looking for something consistent to build on: “How do we standardise our approach without doing one-size-fits-all?” (an ICB Chair). Answer “… it’s about process, not product!” (an academic).
And we continue to see nervousness about stepping out into the complex space “Systems need to concentrate on just three things at a time.” (an ICB Chair)
Helping systems to work with complexity is an area THCA has a lot of experience in. We know that people and communities are complex but there are also some simple rules that govern complex systems. We understand the simple rules for creating health in communities and how they can be applied by systems to inspire optimism and unlock the energy of the workforce and communities to go further faster.
This is indeed a new a new and complex space… but “by jumping in with humility, even though it’s hard.” (an ICB CEO) we might just find that in the end “we want the same thing”.(Belinda Carlisle, Singer Songwriter). That is when the transformation will really start to fly.
For more information on THCA visit: www.thehealthcreationalliance.org