Speaker1: [00:00:00] 15% of the people who live there today won't live there this time next year. The lowest GDP per capita in the country. We think 20% of adults, Londoners are classed as economically inactive. Most people already thought it was integrated. When you get into the health service, the care was absolutely fantastic. Nearly 70% of people felt we don't invest enough money in the health service. Strategic commissioning and population health management is clearly the role of an ICB. Waiting for people to fall ill, pretty much the most expensive way. I wonder sometimes whether we have the purpose. Just having a good idea doesn't make it happen.

Speaker2: [00:00:34] Voices of Care, the healthcare podcast.

Speaker3: [00:00:37] Andrew, welcome to Voices of Care. Thanks so much for coming in to see us.

Speaker1: [00:00:41] It's great to be here. Thank you.

Speaker3: [00:00:43] Well, you've come highly recommended. Matthew Kershaw, I'm delighted that he said that you should come along. Busy time for you. I know we're going to talk about London and the Neighbourhood Health Service for London. I wanted to see if I could start having a look at the big picture since we first spoke, quite a lot of things have been happening. I recall very clearly Wes Streeting, I think it was the NHS providers conference back end of 2024, saying the last thing he would do would be some top-down reorganisation of NHS England, to be no more.

Speaker1: [00:01:16] Abolition on the cards and a number of other changes as well. You're quite right. Some expected and others not. But I'm very happy to speak to any and all of that.

Speaker3: [00:01:26] What's your view on that? Because it's the timing I guess, not to comment on the there's so much going on with a ten-year plan coming along. So these changes, big changes. You'll remember Lansley of course, in 2012, whatever the merits are, they're going to take quite a lot of energy and distraction, aren't they?

Speaker1: [00:01:44] They take energy. You're speaking to somebody who's sort of sat in one office over in London Bridge for the last 15 years, but I've been involved in a PCT, a BSU, a CCG, and I changed the CCG three times and now an ICB. I haven't moved office but we've certainly changed the way in which the system works. So absolutely so. I mean, look, just in terms of the changes I guess on the positive. We started an ICB in the middle of 2022. For South East London, we've been really clear that if we did our job well, then we would find ourselves in a position where people that work for us would either be in a smaller strategic commissioning organisation, or they'd be working with local government on joint commissioning, or they'd be in a provider. And I think that's what Jim and Penny Dash and others are describing. So to some degree, that's what we've talked about. On the flip side of that, 50% is not something that necessarily I was expecting. I'm expecting us to go through a process to work out how the function should work. And in addition to that, the pace of it. To do that in this year, we've got a lot on. I was reflecting back on the sort of timings, we finished our planning for 2025/2026 on the 27th of March.

Speaker1: [00:02:58] The announcements have changed for the 13th of March, so our plans for next year did not include changing the organisations. But it still would point to some of the foundations there. So we are really clear there is duplication in the system. I'm not presiding over a system that is without duplication, without inefficiency. So there's no question on that. And I'm also of the view that strategic commissioning and population health management is clearly the role of an ICB and I'm very clearly of the view that if we train people correctly. And if we come back to this or not Suhail but just to be really clear on it, it's dependent on a couple of things. Firstly, it's dependent on provider collaboration in a scale and sort of a comprehensive collaboration which I've not necessarily seen just yet. And it's also dependent on a different skill mix of staff. And that's why I'm concerned about the pace. So we'll need strategic commissioners really familiar with actuarial skills, for example. I employ people at the moment that don't do that. And so I think some of those dependencies are things we're going to have to be really mindful of. The end goal I'm quite certain, is a good one.

Speaker3: [00:04:12] And that's interesting. So we are still waiting for detail. Penny Dash and Jim are working on, as you say, the key is going to be if it's going to be a distraction. It's also going to allow ICBs to... Pioneers, I think one publication called it for ICB roles. Now let's stay there for a second, because ICBs, STPs, you have come up with a number of acronyms. Previously, you've been through all of them. But it's interesting because South East London was a test site. So it's been a number of years. Of course, the statutory backing was in 2022, but I wonder if there's some key lessons generally that you've learned through this whole period, because I think the King's Fund said that this 50% reduction and the change that there may be is a time to reset and remember what the original purpose for integration was.

Speaker1: [00:05:05] Well, look, let's definitely do that. So the core purpose, I think it's going to change. And whether we have a different number of ICBs, I think I've heard enough leaders say that and I agree with it. So we do need a system sort of leader and convener that's fixated on the population. We say in South East London we should be fixated on the population of two kinds, the population defined by where you live or the population defined by you and other people with similar needs to you. And I think, you know, if you take South East London, but any ICB, we've got institutions that I want to be excellent at being institutions. I want them to be really interested in their patients. I want a body such as an ICB to be interested in the population and bringing together the right groups of people. So I think from my point of view, it is important that we stay true to that. I haven't heard a departure from those principles, and the four are just worth rehearsing, I think. So we're there to improve population health outcomes, as you'd expect. We're there to ensure that we address inequalities. And where I work in South East London, that's our north star. We're there to make sure we improve productivity and value for money. And then importantly, we've got this additional role, which certainly attracted me to apply in the first place, that will make a contribution to economic and social development as the NHS. And so those things are really important that we don't lose sight of them.

Speaker1: [00:06:26] If I think about South East London, how we've set ourselves. So we cover six boroughs. In each of those boroughs we have a place leader. Now, importantly, I don't think we're unique in this, but nearly unique in that we've decided if you're going to have a population focus, you have to have a strong partnership with local government. So in Lambeth, Southwark, Lewisham, Bexley, Bromley and Greenwich, we have an individual that reports to me, but also reports to the chief executive of the local authority. And that's very deliberate to make sure there's a decision maker who's got a balance both sides of the equation. And when we've got it, in my view, absolutely right, is that individual also has a say on public health as well. So if we've got that individual that is looking at the totality of the spend, we feel we're getting to a pretty good place. And so I think the convening of the system, population focused health and care. I guess the other thing we'd say is that there are a number of things we've become deliberately interested in from day one. So our first act was to set up a voluntary community sector charter to make sure that we're investing in the infrastructure of that sector. And we have a strategic partnership with the Southbank Centre. We're looking at creative health and what they can do in the arts to help young people with mental health issues.

Speaker3: [00:07:36] That's quite a recent development that I think was trailed in the press, arts as a therapy and as a healing, I guess.

Speaker1: [00:07:44] Absolutely so. And I could go on. But the point being is we're looking for some of those answers outside of the health service. Waiting for people to fall ill, pretty much the most expensive way, I'm sure you asked me about a lookback, I mean, just a few learnings if it's okay. I mean, the first one, maybe it's obvious, but it's worth saying if you've seen one ICB, I think you've seen one ICB.

Speaker3: [00:08:04] Okay.

Speaker1: [00:08:05] So there's 42. 24 of them serve a population of more than 2 million. South East London serves a population of 2.1 million. Nine of them have a population that's half that, less than half of that. And I think the smallest is Gloucestershire. I'm sure it's a great ICB, but it is the same population as one of our London boroughs. So they look different. They feel different. They also in my experience behave differently. So there's been quite a fixation on whether ICBs are performance managers or otherwise. We haven't seen that as our role. Certainly I speak for South East London. We haven't seen that as a role.

Speaker3: [00:08:42] Strategic commissioning rather than performance management.

Speaker1: [00:08:44] Population health focus. Strategic commissioning, but also convening and challenging people to do better. But we haven't got into that space. And I assume somewhere someone has. And that's why we've got this. So the first is that secondly, we had advocates you mentioned our pathfinder status. We had set ourselves up as a health and care organisation. We had built local government into our decision making. And what's in a letter is quite important. ICBs are statutory boards of the NHS. We had planned for an ICS, with s being the system and a governance that included local government. That has not transpired to be the case. But from my point of view, that is a critical feature that we need to sort of build in. So we, in our integrated care partnership, are directly engaging with the leaders of local authorities, taking decisions hand in glove. And that I think is important. The third one, just to state the obvious, we've been going for a bit under 36 months. I think 33 months have been just gone. For 24 of those, we've been reorganising ourselves. So we're going to have a 50% reduction in ICBs in England.

Speaker3: [00:09:51] Management reduction earlier.

Speaker1: [00:09:53] Yes, but we have spent the last two years removing 30%. And I just also say, and you know, there's no point making any sort of moan about it, but in that period we've had industrial action, recovering from a pandemic and so on. So I wonder sometimes whether we have the purpose. So where we've been focused on that purpose or doing some other things. Just the final one. It's quite important to me. And I don't know that it's controversial or not, but I think ICBs are judged against perhaps the policy changes people intended to make, but not the ones that they did make. Just to be clear. So first and foremost, the incentives are not population focused in the system, but we are a population focused organisation. There is an absolute tension. So on our patch Guy's and St Thomas's or King's College Hospital have a financial income flows from a population way beyond South East London. But we are focused on that population. I'm sure it's just a factual statement, St Thomas's income, as far as it's derived from South East London, there is about 24% of their business. So I don't blame them for looking at a bigger picture.

Speaker1: [00:10:58] And but we are working them as very local partners. Sovereignty. So absolutely, boards are judged for what they do in their organisations. And sometimes that's aligned to what we're seeking to do for the population. Sometimes it's different provider portfolios we've talked about and just the final ones social care. I'm glad you mentioned that. So it is great. And of course as an NHS leader, appropriate funding and infrastructure otherwise. But that hasn't kept pace in social care for one reason or another. So when I look back at my time as an ICB leader, and I often think some of the things we've intended to be doing are not those perhaps, which we've got in sort of the makeup of the model of the system. So that's why I'm quite optimistic about the future. If we're going to look at our model ICB Strategic Commissioner, get the roles, responsibilities and incentives right. That feels like a worthwhile exercise, whether we're doing it in nine months or nine years. So pace feels appropriate, you know, if you're looking at that.

Speaker3: [00:11:56] No. That's great. Now, thank you for that, because I think it's important that we have learnings from the past that you've just shared. But that optimism about the future, whatever that shape is going to be in terms of detail is quite important because actually, at the moment, optimism in the system is needed in one sense, because I wanted to get your view before we dive into the plan for London. The British Social Attitudes Surveys come out very recently, showing the lowest level of satisfaction with the NHS since records began in 1983. 59% of people either very or fairly dissatisfied and very low for social care. So I guess there's an urgent need to communicate and highlight what potentially could happen with some of these changes.

Speaker1: [00:12:41] I completely agree. I mean, there's no getting away from it. I had the stats the other way around, and maybe it's the way I think about things. Just 21% of people saying they're sort of quiet or very satisfied with the service they're getting. 19% if you're going through emergency departments. So I did also note, and maybe I'm clutching at straws here. Nearly 70% of people felt we don't invest enough money in the health service. And the vast majority of them think that that model of free at the point of delivery and the sort of NHS that I fell in love with is important.

Speaker3: [00:13:12] Interestingly, 48%, I think, are willing to have taxes rise and for more money to be spent on the NHS. That's a political decision, but I thought I'd throw it in there.

Speaker1: [00:13:21] Well, I'm not going to say no to that, am I? So and I think when I read across it, most people are asking quite reasonable stuff. They'd like to have really good access to healthcare, and they'd like to have a workforce that's sort of happy and able to work to look after them. I guess my own views on it are of course, I'm not happy with that. I'm optimistic about the future, as I've said. I just think there are a couple of things that it's worth just homing in on when we look at sort of global things around that. The first thing to say is sort of what's happening in wider society. What is it for the NHS to do by itself and what do we do with partners? I spent an afternoon in Peckham with our social prescribing team, sat through about 10 or 11 consultations, and obviously I won't go through the personal details, ten of the 11 or over 90% and referred by a GP, ostensibly to talk about a health care condition. As far as I can see, they're exclusively housing conditions. Either the quality of the housing, the availability of the housing, two people there who were concerned they couldn't afford a GP letter so they could get better housing. The sadness to me of that is that in that borough, I don't think you need a GP letter to get better housing. So we've got a systems hard to navigate and health issues manifesting as health issues actually unrelated.

Speaker1: [00:14:40] And so a bit of me given it's the Social Attitudes survey, not a survey about the appointment you just had, is how much of this we need to fix with partners and how much would it. It so happens that my mother had a stroke a couple of months ago. Just to be absolutely clear, when you get into the health service, the care was absolutely fantastic. Staff brilliant. No complaints whatsoever. But the trade offs really not great when you need to coordinate someone to get into a hospital. At the ED department, that felt chaotic and I'm someone who knows the system. Even worse, trying to get a discharge with an appropriate care plan. So although we have a statement about the health service, I think there are a couple of points from my recent experience and an anecdote. The trade offs, the handoffs between people seem to be something we need to focus on. And then just a real look at what's affecting people. I've talked about housing. I could have talked about employment. I could have talked about fear of crime. And so all of those things, if we're not looking in the round and I know we're going to come on to a neighbourhood health service, but it's why I think it's important. It is a neighbourhood. And all the things that happen in that neighbourhood, not the things that happen when you fall ill.

Speaker3: [00:15:50] No. Absolutely. It's important that we have that bigger picture. My late father had a stroke and I had to do, I don't know, the system as well as you do, of course, but I've been around it and it was Byzantine and challenging, so I fully understand that. Thanks for the comment on the bigger picture. I think that takes us, I mean, social prescribing you mentioned, I think it was social prescribing day, a few weeks ago. Let's talk about London, and the idea of a neighbourhood health service. This is something that's been trailed by the government as part of its health mission. It's part of its manifesto. I hate to remind you, I think it's that your quarter century anniversary since you graduated. And that was the same year as I believe the NHS plan, as it was called then, came out under the auspices of one Alan Milburn, and they highlighted the need for PCTs to absolutely focus on transforming community and primary care. So we're sort of a bit of a deja vu place that we're in. Set out what work you've been doing because I think the case for London is very powerful. It's facing. I think you said a perfect storm in terms of population health inequalities. I think we can begin with frailties of over 65. Those numbers are set to rise enormously.

Speaker1: [00:17:12] Well, look, I mean, just in the abstract and absolutely want to bring it to London. That's what I do in the abstract. I understand a neighbourhood health service to be, as I said, the things that happen to that population in an environment they understand where they live their lives, as opposed to where they sort of experience their illness. So the first thing to say is, if a neighbourhood health service is defined as something that brings in criminal justice, brings in housing, all of the aspects not just of social care, but of local government and the health service. Then we're talking about the whole problem and not...

Speaker3: [00:17:44] A bigger piece.

Speaker1: [00:17:44] Yes, not just a bit of it, but that's how that is how I understand a neighbourhood health service that we're essentially trying to organise care around populations defined by your postcode. So we want to get to a position where say you live in W6, where I live in, I live in Camden and my neighbourhood is understood to me and I know how to get services there. I might also be in a population, as you said, of people. Fortunately I'm not at the moment but one day who are frail. So I also want to have good access to a multidisciplinary team in that neighbourhood. So I guess the main point for me is in the abstract, if it's beyond the health service, we're on to the right thing and to the Secretary of State's three shifts and perhaps three shifts. It's kind of delivering on that left shift. So move to prevention. It's delivering on moving acute to community. And it's happening alongside digital. And so if those things are true I think we're on to a good point. Why London? So, I would say this is not popular outside London. London is a bit different. It is different. So a neighbourhood health service here is going to be really quite specific and balance of something that is really tricky. So the first thing to say is we've got the most diverse metropolitan area anywhere, certainly in this country. In Southwark, where I sort of started off in South East London, 15% of the people who live there today won't live there this time next year. So there's a lot of people churning through equally in that borough. You'll find the youngest Londoners and you'll find over 160 languages spoken. But in London as well, you also moved down the motorway, to Bromley, and you'll find the oldest Londoners, and you will find actually inequalities of a different type. But in the same place. So why London? Well we need to have locally sensitive areas. But equally we've spoken to Londoners. We've spent the summer having a deliberation.

Speaker3: [00:19:40] A deliberative engagement.

Speaker1: [00:19:41] Absolutely. So, enduring or ongoing conversation with a group of Londoners, slice across society, of course, to say, well, what is it you would value? And I don't know if I was surprised or not, but essentially to say we do like this idea of locally sensitive services, but we really like the idea that we've got consistent core services. We know how to get hold of them. And this consistency bit is really important. So in London we think there's a particular case. We said say well actually this should be a core offer, not just because Londoners have said it, but also our institutions do not necessarily recognise, nor do Londoners the boundaries that we set. So when people sort of walk across that road that stops you being in Lambeth or South East London and finds you in Wandsworth in southwest, there is no alarm that goes off. So we just need to bear in mind if we need to organise things around these institutions and the valuable things they provide to recognise that St Thomas's ED, they'll discharge people today in large number to 14 different London boroughs, but they can't do things 14 different times. Equally, I can't say to all of those 14 London boroughs your populations are the same because they're not. So we're trying to navigate our way through in London to say there is something particular here that we need to do. The perfect storm is probably true everywhere. It's definitely true in London. So essentially we are saying economic and health inequalities are driving ill health, that driving that ill health is putting a pressure on struggling services. And because they're not responding, perhaps as they might, that is then making those same issues worse. And so that is our perfect storm.

Speaker3: [00:21:20] And you've talked about a couple of interesting things that I've seen that struck me. And I'm a I still regard myself as a Londoner, even though I live in the village in Kent. Heart's always in London. The level of health inequality is quite significant. I'm just going to look at poverty stats 24%. I think of Londoners own household expenses into account are living in poverty. I think that goes to 34% for ethnic minorities. And I think it was the Marmot review at the Institute of Health Equity. This is costing billions of pounds. And I guess one of the highest priorities is the is it 2.6 million people that are now. I don't like that phrase, but economically inactive because of ill health. That's a big issue as part of the objectives of the economic contribution that the health service can make.

Speaker1: [00:22:07] Well, look, I mean, I wanted to touch on this and forgive me. I wrote some stats down so didn't get them wrong. But we think 20% of adult Londoners are classed as economically inactive 20%. And we think 7 in 10 of those want to work. And that's not my opinion. That's the Pathways to Work Commission, which.

Speaker3: [00:22:24] Alan Milburn chaired.

Speaker1: [00:22:25] I believe so. Exactly. So and we also think, the economic case is absolutely there, that if you get 100,000 people back into work, that's getting on for £4 billion of net benefit to the economy. So there's a real reason to do it. And consequently, if I run a health service or a neighbourhood health service that focuses on what happens if you fall ill or what happens when you haven't been working for this period. We are doing half the job. So there's some direct things we can do. South East London's NHS employs 49,000 people, by the way. Our health and care system raises that to 100,000 households in South East London. 1 in 10 of them have someone who works directly for us or mother, son or husband.

Speaker3: [00:23:09] That's the quintessential anchor institution.

Speaker1: [00:23:11] It absolutely is. So we're focused on that. To your point, I think perfect storm is there. I'm the London lead for primary care. And I just also just want to give a little bit.

Speaker3: [00:23:22] I wanted to touch on if I can because primary care people, whenever they think about it, they always think about GPs. No it's not. It's beyond GPs. But I was stunned when I looked at some of the numbers. I think it's large percentage of the GP practices are pre 1948 buildings, and you've got 20% reduction in the number of GPs over the last decade. Is that right?

Speaker1: [00:23:43] Absolutely. So the reason sort of I mean, first and foremost, I think primary care is where it's at. By the way, I know you speak to a lot of acute care people here. So just sort of clear primary care if you get that right. I think this health service stands a very good chance of thriving. But it's right. So primary care is beyond general practice. But let's just focus on general practice for the last decade. 20% of practices have reduced. It's worth getting into why though. So half of those 20% have changed their business model. They've become bigger. So we've got the same service provision. They're organised differently. And the reason they've got that scale is so that they can survive as a business model, deliver local services. And it's a natural thing to do. The other half have stopped those businesses either because it's become unaffordable or for some other unsustainable reason, and we think it will increase. We've got the lowest GPs per capita in the country. We've got more highest rate of departure, lowest rate of joiner. So it's going to get worse. And I was concerned that we had more GPs over 60 than anywhere else. It's twice the number as some parts of England as well. So there's no reason to believe that we just watch this and it will change. And you're quite right to call out the wider primary care fraternity. And I do as well, community pharmacy. It's not vastly different, to be really clear.

Speaker3: [00:25:04] And the added, I guess the added pressure there is that I think the Royal College of General Practitioners, whose chair we've had as an honoured guest. The stats are showing because of burnout and all these issues. There's significant numbers are suggesting that they will stop practising.

Speaker1: [00:25:19] Absolutely. And so I think there's an opportunity for us to take action now. I'll link it back to a neighbourhood health service because essentially the two are intertwined. We won't have good general practice and primary care if we don't have a neighbourhood health service. We won't have a neighbourhood health service if we don't have good general practice and primary care. So, I mean back to this sort of case for change bit. We think that at the moment, we should get to a position where we're defining what a neighbourhood health service is for Londoners. We think that it is a difficult task. So I don't know how you feel about the services you receive, but one of the reasons it's difficult to explain an integrated health service provision is that most people already thought it was integrated. And the point at which they realised it wasn't is when my mother or your relatives have a stroke and then you realise that it's not as integrated as you thought it was. So describing something maybe quite surprising to people that it's not integrated.

Speaker3: [00:26:14] I think the other.

Speaker1: [00:26:15] Thing just to do.

Speaker3: [00:26:16] It, people, I think, make that assumption because, I mean, I may be wrong, but I looked up the idea of promoting primary and community care alongside an integrated model. And I think I found the hospital plan of 1962 was promoting that. So we're still okay?

Speaker1: [00:26:30] I think that's absolutely right. But so if we're describing what it is to people, I mean, first and foremost, I'm just saying neighbourhood, I think some people might argue a neighbourhood is a couple of streets that they live in. To be really clear, what we're trying to describe healthier communities here and the community sort of size we're talking about is a 50 to 100,000 South East London, have 25 neighbourhoods. We'll organise our care there. And importantly, the neighbourhoods that we think are residents recognise. But also local government recognises in terms of the way they organise services. So that's the first thing to say. Secondly, we think we're trying to do two things. So firstly, we're trying to keep you well so that that left shift. So I want you to be able to put your postcode in to whichever way you access the health service and say, this is the community that I live in. These are the things that are already accessible to me, of which there are many and many people who don't know how to navigate them because we don't do a good enough job of explaining it. And that's how you might stay well. And you'll have a core general practice offer. There'll be a team around the community that can support you, and they will have social prescribers, and they will have housing advisers and people that can help you when you get into trouble with debt or otherwise. So that's the first thing. But equally, each of those neighbourhoods will be served by an integrated neighbourhood team that might focus and have access to specialists on your frailty or in actual fact, the three that we're targeting.

Speaker1: [00:27:50] So children and young people, very often, kids with asthma and frailty, and then those people with multiple long term conditions or comorbidities. So in that instance, we've got a sort of population of a different kind. And we're trying to make sure it's really easy for local, community based clinicians to access specialists and make sure that's there. I guess for us, though, we might have 25 natural communities in Southeast London. That's great for service delivery, locally responsive care. It's pretty much awful for everything else. I don't have the scale then to run the infrastructure, the HR department, the transformation resource that I might need to help people do things differently. So we think there is a sweet spot here. We think that the NHS plan, I think the NHS plan will talk about units of 250 to 300,000 population. That's the size of a London borough. So I think there's a sweet spot here that says local government is organised around London boroughs. So social care, public health and all the rest of those things. And we are able to organise in each borough, an infrastructure platform. I call it an integrator. That name isn't supported everywhere, by the way. So if you've got any ideas, please let us know. But essentially, to say this isn't going to organise itself, just having a good idea doesn't make it happen. We think there are, to your point about anchor institutions, existing organisations in each London borough that.

Speaker3: [00:29:13] Could act as.

Speaker1: [00:29:14] That could act as that. Now, I've no direct interest in which particular type, provided they can do a few things. Can they provide you with not just a safe employment, but can they provide you with a career portfolio? So let's imagine that it was somewhere like St Thomas's in the borough of Lambeth. They provide the acute and community care services. Let's imagine you're interested in being a nurse in Lambeth. So at the moment you can go and work for a hospital. You can go and work for general practice. What if you were able to be a Lambeth nurse where you can rotate through? There's a career pathway. There's training. You're not limited by the scale of your employer.

Speaker3: [00:29:52] And potentially you could also as a couple of guests on our podcast have advocated including Skills for Care is nurses could also have time in the community in a social care setting.

Speaker1: [00:30:05] Absolutely so. And I think that that also ties back to staff morale, by the way. So walking other people's shoes and understanding where they're coming from. So I think interesting joyful work if we can make it happen. But it does require a bit of a shift. And so I'm a big advocate of the general practice model. But I'm an advocate of what it does for patients and registered patients, the business model behind it. I'm just interested in is there an equal partnership we can create between general practitioners and larger institutions, so we can both benefit here? I clumsily called it a sort of, a joint venture. And in each of the boroughs, can we bring together the scale and heft of some of our bigger institutions in a genuine partnership with the smaller general practices, community pharmacies otherwise, and say, is there a different way to do this? My contention is there is. I don't want a third party to do that. We want it to be owned. And the benefit of having an NHS organisation is they're also in control of some other staff. They're in control of their doctors.

Speaker1: [00:31:06] They're theologists, as I call them. So can we work on job plans that that promote community based working on a consistent basis? And so and we can't afford another tier of administration as we're learning in ICB land at the moment. So when I put those things together, very interesting neighbourhoods, natural communities, people recognise what happens behind the scenes. The infrastructure happens. And I always go back to in my career, I think, attest to this. General practice is a treasured part of the system. The business model does not provide a chief executive of general practice that can advocate and lobby and get some of the infrastructure bits that other parts of the system rely upon. We do not have a head of transformation in a general practice in South East London. And if we want to maintain a population Focus the general practice of scale the scale really successfully, but not necessarily around a specific population. So I think place becomes really important. There's a couple of things in the work that we've done. So first of all, we think we're saying nothing unless we're saying it together.

Speaker3: [00:32:10] Okay.

Speaker1: [00:32:11] So in terms of our work on a neighbourhood health service for London, and we're hoping the documentation that we've put forward, has the sign up, actual sign up of London councils. We very much want the London wide mix to.

Speaker3: [00:32:26] Voluntary organisations.

Speaker1: [00:32:27] Voluntary sector and of course the five ICBs and NHS in London, NHS England Today and the Department of Health and Social Care going forward. And we think we've got them. So when we say that, then there's something about saying that together and organising on that basis.

Speaker3: [00:32:42] And that primary care vision you've set out, there's a couple of things that come to my mind. I mean, it's very much in the spirit of Claire Fuller's review in the stocktake about integration. I guess it has quite significant implications for workforce. Workforce training. I know Mr. Streeting has said he's going to revisit the long term workforce plan, which is out in 2023, so there's going to be some re-envisioning of multidisciplinary teams and training in all of this, I think.

Speaker1: [00:33:09] Absolutely. So, look, I'm not a workforce specialist, but it just makes sense to me that the professionals that train together and understand and I think have a mutual respect for disciplines, is going to help with productivity. We're going to help with morale, maybe generate different portfolio careers for people. It's quite a privilege being a system leader in London. But one of the reasons for that is you get to hear a lot of different perspectives. It is always a dismay to me if you're in a very busy department. I don't blame people that say, oh, well, you're here because mental health haven't done their job or general practice. But just to spoil the surprise here. If you're selling a general practice waiting room, they say, well, you know, actually you've been you've been sent here because outpatients got it wrong. So I think this idea of training people together and a system is absolutely key.

Speaker3: [00:34:03] I'm bound now because we're talking about obviously this great initiative. I think you've been working on it across all of these organisations with the local authorities and the mayor's office as well, etc., since 2024. Is the horrid concept of the money and the resource flow? Because this transformation, this left shift, if we look at the fact that it's been trailed integration for a long time. But my understanding is if you look at the decade prior to 2010, acute services took up about 49% of the NHS budget. 2021 it was 59%. Primary care dropped from 28% to 18. So the policy shift five year forward view. People might remember that was going towards integration, but it was sort of a right shift when it went to resources. That's going to require some advocacy and change. Right?

Speaker1: [00:34:58] And I guess it might also require different people taking decisions about where money gets to. So I don't particularly want to have a conversation about other three letter acronyms that people won't like. And I know people talk about accountable care organisations otherwise. But if we just talk about the use of money. I want to come back to what we should be doing now and what we might do in the future, but just if we forward mind, we do want a set of organisations in a provider collaboration responsible for a limited pot of money and say, are we deriving best value for this? And the limited examples I've been involved in, particularly with acute and community integrated organisations, they rapidly, when faced with a single responsibility, move money towards the community. But not if we set up a situation where we are having bilateral discussions about how that money works. So I do believe at a point in time, we need financial flows that allow a population based budget to be made available to a group of providers who can take decisions together about what best value looks like. And in doing this work, and you're right, we've been working on it since the summer of 2024. In truth, we've been working on it probably the last 24 years. But anyway. But in terms of this immediate bit, what we've said is no change is not an option.

Speaker1: [00:36:12] Waiting for all the answers is equally not an option. So at the moment, the reason why I'm focused on integrators in each borough and is that you can do that now. You can have that level of collaboration. Actually, it would be fantastic to have financial flows pointed at this. And I'd like to talk a little bit about how we incentivise primary care in just a moment if I might please. But in terms of you could have organisations that having had their allocations and contracts signed by people like myself and ICB, they can choose to pull those resources and they can do that right now. So I do want to move rapidly, not to the idea that everything has to be set before you do anything. And we could move in a borough to organisations agreeing to share the money and using it in a different way. So the first thing to say. Secondly, we do have to have incentives that point in the same direction. So I have been impressed, not least during the pandemic, by what primary care networks can do groups and practices collaborating. But primary care networks currently drive a level of incentive to general practice, to work with general practice, not to work with other organisations.

Speaker3: [00:37:23] So that needs to expand.

Speaker1: [00:37:24] Absolutely. So and to work with other practices, not necessarily in their same geography. So they're geographically aligned. So there are a few things that I think we sort of go, we can do now without change. There are smaller things. Can we change the way in which we incentivise in the current world? And yes, absolutely. Financial flows would have to be quite different going forward.

Speaker3: [00:37:46] And I wanted to cover the examples that you've seen already because looking at the history of collaboration, looking at integrated care systems, there's been some evidence to show a systems approach to workforce has been working quite well in different parts of the country. There's been a recent report around neighbourhood work that's been done by Sandwell, for example, etc. So that must give you some, I guess, hope and positivity that this is not only going to be received well, it can actually deliver the better patient outcomes and value that you're looking for.

Speaker1: [00:38:18] So I think look, it's often said and I think the Secretary of State is right to call it out, that all of this is working somewhere. And so I do take hope and encouragement from that. I just want to be clear that we understand the real transferability of some of those things and the circumstances that underpin them. But you're absolutely right to call that out. I'm obviously South East London centric, but at the moment I'm very clear that each of ICBs have got boroughs where this stuff is taking off. In Westminster and North West London, we've got absolute innovation doing the things that we're talking about right now. Sutton in South West London. If I go over to City and Hackney in North East, and then of course, in my own part of the world, I think the work in Bexley and in Lambeth are all showing that there is something here and we can demonstrate it. Getting that scale and being able to spread that is absolutely the challenge. I don't think it's as simple as saying to one organisation, can you replicate one partnership. Can you replicate what's happening over there? The start points are different. The culture and history are different. So we do need a bigger oomph. But absolutely there are. We were able to point to models where it's happening now.

Speaker3: [00:39:30] Just coming towards the end of our conversation, but something that struck me as being really important, it's something you've mentioned in some of your documents, is that to enable all of this to happen. There's some big things that need to be happening at national level. We know that there's transformation, but leadership is going to be a huge enabler of this. Can you talk to that you as a leader and what's going to be required of the leadership at all of these different levels to translate this neighbourhood health service into a functioning, recognisable entity and pathway for patients?

Speaker1: [00:40:04] I couldn't agree more. And I sort of put it another way. We move at the pace of trust. And so I think a lot of the work that we've been talking about, and indeed I've spoken about it in quite a structural way now, essentially relates to culture and what we're able to galvanise. So there's a reason we've gone for a leadership consensus around London on the neighbourhood health service, because we think all parts of the system need to be able to work in that basis. We think absolutely important that incentives are aligned. And yes, there is a leadership challenge here. And I think there's a specific challenge. If you wouldn't mind me saying so, some of those places where particularly this neighbourhood and primary care general practice bit has worked is where we've got not just distributed leadership but equal leadership. So I'm hoping we will find these place integrators that are led by genuine partnerships of major foundation trusts, but also very local clinicians who have working in primary care, who have come together and taken those decisions together. And I think that that perhaps is a leadership challenge that we're essentially pointing to that's what we need.

Speaker3: [00:41:21] And I think the progress as a function of trust is really important. I was reading the NHS Race and Health Observatory's report, it showing that in primary care, certain groups, certain parts of the population don't have the trust in local services, particularly for South Asians. A third only using primary care. So this is part of the bigger picture of communicating what you're trying to do, so that people actually see that this is a tremendous benefit and designed for them, co-designed actually in many ways.

Speaker1: [00:41:50] So we've been really good at asking me sort of my learnings from working with an ICB and system leadership roles. And that's absolutely right. The pandemic, but most particularly the vaccination programme was absolutely a lesson to me. I had laboured under the impression that if you work for the health service, you had in some way through no action earns the trust of local communities that became very clear that that is either absent or fragile for many of our communities in London. So building that back up, having a locally appropriate approach to communities and what we termed in the vaccination programme is hyper local interactions is really important. I think it boils down to a population health management approach adopted by leaders across the system that says, well, we need to be interested in those communities if we're going to understand how we will build trust. I don't wish to sort of rehearse things you will have heard are obvious. But in that vaccination programme, we did rely on other members of the community and trusted leaders otherwise to help us in a sort of partnership or a coalition for delivery. I think that's what we're looking to replicate in neighbourhood health services now.

Speaker3: [00:43:04] Absolutely. One final point. If I can end, remind you of your post, the 2022 act, the statutory basis for ICBs. Except I think in your first public board meeting, members of the public were there, and I think you were presented with a with a heart that was to show that the heart should remain central to this. I wanted to end on your heart, clearly very much enthused around the possibilities of what this change could bring.

Speaker1: [00:43:34] So we did a couple of things. I'm glad that you had had a look at that. So we have a relationship with what's called South London lessons. We engage with up to 5000 South Londoners, essentially to keep us grounded in the work that we are doing is, as we say it is. And so I guess success for me is locally relevant responsive services. And I hope that we are living up to that. The health service is very dear to me, the communities of South East London. I don't know how well you know it are apparent everywhere you go. It is an exciting place to work. And so we want to be very definitely connected to those people. So I'm absolutely delighted that you could observe that. The other thing we did when we launched our ICP was we had Sir Michael Marmot launch our ICB to essentially set the tone on day one. And the tone was that the wider determinants of health were incredibly important to us. So in our setup, the way in which we're doing, and certainly the thing that excites me is that I can be part of a health service that is as interested in those wider determinants as what happens when you walk through the door of a hospital. We're hoping to get both right, by the way.

Speaker3: [00:44:47] Well, you're speaking to someone whose children, some of whose children live in Greenwich and Woolwich. So this is really important. On that note, hopeful note and compassionate note, if I may say so, Andrew Bland, thank you very much for your time today.

Speaker1: [00:45:01] Thank you very much.

Speaker3: [00:45:02] It's been a pleasure. If you've enjoyed this episode, please like, follow or subscribe wherever you receive your podcasts. And if you want to learn more about how we're turning the dial on health and social care, please visit newcrosshealthcare.com/care. In the meantime, I'm Suhail Mirza. Thank you very much for joining us today and I look forward to seeing you on the next episode.

Speaker2: [00:45:21] Voices of Care, the healthcare podcast.