Number of repeat prescriptions ordered via NHS App up 92% in last year

By Integrated Care Journal

2.4 million repeat prescriptions were requested through the NHS App in April and more than 500,000 repeat prescriptions are now booked through the app every week.

New figures released by NHS England show that since the NHS App’s launch in December 2018, more than 42 million repeat prescriptions have been ordered through the app. In April 2023 alone, the NHS App enabled 2.4 million repeat prescriptions to be ordered, compared with 1.7 million in April 2022 and 393,000 in April 2021.

The latest figures represent a 92 per cent year-on-year increase in repeat prescriptions ordered via the app from 13 million in 2021/22 to 25 million in 2022/23. The increase comes ahead of the NHS’s milestone 75th birthday on 5 July, when the achievements and innovations of the NHS and its staff will be celebrated.

Patients across England were reminded of the benefits of using the NHS App to order repeat prescriptions, ahead of the upcoming bank holidays in May.

Chief Pharmaceutical Officer for England David Webb said “we are reminding people of the excellent benefits of the NHS App,” particularly in the context of May’s long bank holiday weekends limiting access to GPs.

Webb continued: “Patients can order repeat prescriptions through the app at a time and date convenient to them and access community pharmacy information about local healthcare advice and services available during the bank holidays.

“The NHS has always innovated and adapted to meet the needs of each generation and as we approach the NHS 75th birthday, the NHS App is yet another fantastic example of how we are doing this.

“The app offers a digital front door for interacting with the NHS with a host of new features launched in the last year– empowering patients to access services from the comfort of their homes. As ever, if you need care during the bank holiday weekend, come forward – using 999 in life threatening emergencies and NHS 111 online for other health concerns.”

Some of the features available on the NHS App enable patients to view their GP health record, nominate their preferred pharmacy, find local NHS services and get health advice via 111 online.

New and innovative features continue to be rolled out to help patients access convenient and high-quality care when and where they need it. Patients in many parts of the country are now able to view and manage their hospital appointments on the app, and many GP practices are now sending NHS App notifications to patients with appointment reminders and other messages relating to their care.

Health and Social Care Secretary Steve Barclay said: “Technology is transforming the way we deliver healthcare for patients, and I’m determined that the NHS App plays a vital role in this.

“Repeat prescription orders through the app have increased by 92 per cent in the last year – including 2.4 million in last month alone. This is freeing up valuable time for clinicians and helping people access services easily and conveniently from the comfort of their own homes.

“A host of new innovative features have also been rolled out– from viewing GP records to finding local health services – offering a digital front door to the NHS.”

The NHS App has now recorded more than 32 million sign-ups (as of April 2023).

More than 28 million of these have fully verified their identity through NHS login, which means they can now access a variety of digital healthcare services quickly and securely through the NHS App.

Dire state of social care sector undermined pandemic response, study finds

By Integrated Care Journal

Structural weaknesses, unaddressed by successive governments, left social care struggling to provide the service and protection that people needed during the initial waves of Covid-19.

Lack of visibility of the sector, unclear accountability, insecure funding and poor workforce pay and conditions impacted the sector’s ability to implement protective measures in a timely way, according to a new report published by the Nuffield Trust.

The report is the result of a two-year joint study between the Nuffield Trust and the London School of Economics, and looks at issues which emerged with the Covid-19 response in the social care sector in England. Focusing on the initial four months of the pandemic response (February-May 2020), it found that the fragmented nature of the system and a shortage of civil servants working on social care contributed to confusion over who was responsible for decisions and implementation in the Covid response, which, for example, undermined the effective distribution of PPE and testing for care staff.

The study also concluded that successive governments failed to respond to concerns surrounding pandemic-preparedness identified by multiple cross-government planning exercises. Amid a poor understanding of the sector and its capabilities within government, many smaller care providers were unable to effectively accommodate infection control measures and adhere to the slew of ever-changing guidance and regulation, with disastrous consequences for the nearly 20,000 care home residents who died in England and Wales in spring 2020.

Natasha Curry, Deputy Director of Policy at the Nuffield Trust, commented: “What happened to social care at the start of the pandemic represents the consequences of letting one of our most important public services languish in constant crisis for years. Those early months exposed an array of weaknesses within social care that impacted the shape, speed and effectiveness of the response. Many of these difficult challenges could have been eased had warnings been heeded. Governments of all hues have failed to make social care and those who need it a priority.”

Drawing on interviews with sector experts, workshops with social care stakeholders (including people who use care), policy documents, and literature, the report identified areas that could put social care on a more resilient footing in the future.

The report found:

The government, NHS England and Public Health England missed opportunities to prepare the sector for a pandemic, or other crises, in the years immediately before Covid-19. They excluded social care from pandemic-planning exercises such as Exercise Alice. After exercises that did include the sector, such as Operation Cygnus, action was not taken to address the problems that were identified. Once infections took hold in England, the government did not sufficiently apply pre-existing knowledge of infection spread in care settings.
There had been no dedicated director general for social care in the Department of Health and Social Care (DHSC) since 2016. No adult social care representatives sat on the Scientific Advisory Group for Emergencies (SAGE) in the opening weeks of the pandemic. This meant social care leaders felt largely invisible, despite the critical role of the sector.
The wider Covid-19 response, which was perceived to be hospital-focused at the outset, caused many issues for social care staff because the structure of the workforce and what their jobs involved were not well understood. For example, a lack of access to Covid testing and sick pay had far-reaching consequences for staff when self-isolation policies were in place, especially for those on zero hours contracts.
The long-term tendency of governments to allocate funding to social care in the form of sporadic injections of cash limited the scope for strategic investment and had implications for how robust the sector, and its infrastructure, were when entering the pandemic. Many providers of care, which are often small businesses, entered the pandemic with little or no cash reserves.
During the pandemic, the succession of emergency funding pots offered to social care initially took a long time to reach the front line, and their short-term nature prevented strategic planning. While seen as a lifeline for care providers, extensions to the funding were frequently announced with only weeks, days or in one case hours before the end of the scheme and did not allow those on the front line to spend it to meet the needs they could see.
There was a lack of data and information about who uses and provides adult social care services and how to communicate with them. Covid-19 has accelerated efforts to collect data, and this is helping to lay the foundations of a robust source of standard data.
The government did not adequately consider the fragile state and the complexity of the adult social care infrastructure, in particular residential care buildings and equipment. Small organisations, that make up much of the sector, lacked the back office capacity to interpret continually updated guidance and outdated care home buildings struggled to isolate or group together infected residents and to accommodate wider infection control measures.

There has been some positive progress in learning from these problems, with the Department of Health and Social Care (DHSC) bolstering its social care capacity and expertise and the signaling of it as a priority area with the appointment not only of a specific director general but also a chief social care nurse.

Following the first four months of the Covid-19 response, progress was made to plan for ongoing outbreaks in the short to medium term, for instance with the establishment of the social care taskforce in June 2020 and the decision to continue to provide PPE purchased centrally. The smoother subsequent rollout of vaccinations in social care settings pointed to improved collaboration between the government and social care partners, and the prioritisation of carers in the vaccination rollout was widely regarded as a positive step forward.

Adelina Comas-Herrera, report co-author from the Care Policy and Evaluation Centre at the London School of Economics and Political Science, said: “The pandemic has had a tragic impact on people who use social care and those who provide care, unpaid and paid. This has been a shared experience internationally but the evidence suggests that some countries were able to cope better than others. Our research shows that social care in England needs a system-wide reform to be able to respond not just to emergencies, but to the implications of longevity and competition for workforce with other sectors.”

Care Minister, Helen Whately, said: “During the pandemic [the government] supported social care with £2.9bn in specific Covid funding, sent out more than 230m Covid tests to care homes and prioritised social care for Covid vaccinations. We are committed to learning lessons from the pandemic and are investing up to £7.5bn over the next two years to put social care on a stronger financial footing, help reduce waiting lists and alleviate workforce pressures.”

The full report can be accessed here.

Lack of shared understanding slowing the shift from hospital to home

By Integrated Care Journal

PA Consulting global research on unlocking the next frontier of healthcare finds that poor mutual understanding between clincians, medtech and pharma is hindering the development of the hospital-to-home shift.

As the NHS continues to face challenges in recruiting and retaining the healthcare workers hospitals need, the number of delayed discharges rapidly increases and preventative and personalised treatments come of age, the opportunity to deliver better healthcare outcomes by migrating care from hospitals to homes is widely recognised.

However, PA Consulting’s global survey of 550 leaders across public and private healthcare found that nearly two thirds (65 per cent) considered a lack of understanding of healthcare systems and pathways by medtech and pharma as contributing to slow adoption in the next five years.

The increasing burden of disease and chronic conditions, compounded by an ageing population, have escalated costs and impacted health outcomes. Despite global respondents to PA’s survey believing moving care from hospital to home will help curtail rising healthcare costs in the next three years, PA’s research demonstrates a lack of understanding, collaboration, and co-development between stakeholders.

While healthcare leaders see medtech and pharma’s lack of understanding of healthcare systems as the biggest barrier, health and care professionals are wary of under-developed infrastructure, technological and financial implications, and clinical and reputational impact.

The report identifies the following opportunities and challenges:

Healthcare leaders see the opportunity and 72 per cent say their organisation is prioritising at-home solutions – including diagnostics, monitoring, and advanced drug delivery systems – to provide patients with quality care while protecting capacity.
Seven in ten global healthcare leaders (71 percent) say their organisation has a strategy for migration from hospital to home but believe health and care professionals doubt that treatments delivered at home are as safe as those delivered in traditional settings.
Today, less than a third (28 percent) of healthcare leaders say physicians are motivated to transition from hospital care despite the positive medical outcomes. In five years’ time – when it is expected that hospital at home will be mainstream – this figure rises to 40 percent.

The report highlights four key steps that can accelerate the shift from hospital to home care:

Engaging all stakeholders to collaboratively define future care. Co-designing products and services with partners and patients is key. Focusing on outcomes, not equipment, and on people’s needs, not technology will improve patient outcomes. In one council area, this approach has seen wearable detectors, smart sensors, and personal GPS devices support various health conditions at home and delivered £30 million in net financial benefits.
Differentiate through experience. Create better, safer, easier experiences for patients and professionals. Patients have power – their attitudes dictate treatment effectiveness and drive care pathway changes. In renal dialysis, for example, patients called for dialysis machines for use at home to reduce time spent in clinics, actively shifting site of care.
Deploy digital with intention. Digital solutions are more likely to see widespread adoption where there is a clear link between solution and value. New Prescription Digital Therapeutics (PDTs), for example, are helping to rethink current mental health care. PDTs enable lower priority sessions to be completed via an app, reducing long waiting lists while allowing psychologists or psychiatrists to focus on acute patients.
Show the value. Patient quality of life, health equity, and community impact are key facets of the new understanding of value. Better health outcomes as a result of shifting site of care will benefit patients and reduce pressure on healthcare practitioners. For example, Medtronic’s diabetes monitoring system pre-empts Hypoglycaemic attacks, assessing patients’ biomarkers against wider data trends and population statistics. This is one step closer towards autonomous diabetic management.

Amanda Grantham, healthcare expert at PA Consulting, said: “As hospital to home solutions become more economically viable, match and exceed the efficacy of treatments delivered in hospitals, and improve the experience of patients and professionals, the dynamics of healthcare will change. By co-developing solutions, ecosystem stakeholders can open up market opportunities and create a win-win model that delivers value for all.”

Hilary Thomas, health and life sciences expert at PA Consulting, added: “Market leaders across the worldwide healthcare, medtech, and pharma landscape are pushing the boundaries of possibility, using breakthrough technologies, science, and data to redesign care pathways that unlock new opportunities. At the heart of this opportunity is shifting the site of care to the most appropriate, most economic location.”

Elective backlog and care priorities: a call for localised solutions

By George Batchelor and Lucia De Santis

Edge Health’s George Batchelor and Lucia De Santis explain the need to develop localised solutions to drive the NHS’s elective care recovery.

March 2020 marked an unprecedented change in the NHS and healthcare provision. As resources were diverted to the pandemic response, virtually all elective activity ceased, and the healthcare system transformed into a huge acute response machinery. We knew this would not be a sacrifice without consequences, but it was worthy of the stakes at play – millions of lives affected by COVID-19.

Fast-forward three years: the pandemic is now over for many people, but its impact on the NHS remains. This impact goes beyond the ever-growing elective backlog to include a fundamental shift in how care is provided, as well as a host of top-down targets that place increasing challenges on care providers.

The state of the elective recovery

Many will be familiar with the dire state of waiting lists for consultant-led elective care that topped 7.2m in October 2022 – a 64 per cent increase from March 2020 and with a median waiting time of 102 days.

Amid efforts to tackle the backlog, the recovery strategy has pushed for “doing more” with an ever-increasing range of performance measures to drive increased throughput and avoid adverse incentives, including: achieving zero 65-week waits by March 2024, increasing completed pathways by 110 per cent, increasing valued activity by 104 per cent, performing all diagnostic tests within 6 weeks, and several more.

Competing targets can be confusing to navigate and add pressures to already stretched systems, but they also fail to account for novel care challenges and regional variation. Working closely with trusts and ICBs, Edge Health has encountered, again and again, a stark increase in patient complexity since the pandemic and the consequences of a depleted, exhausted workforce that don’t show up in figures and targets.

To add to this, Covid has also prompted a greater focus on prioritisation and clinical urgency in allocating care, as opposed to a first come, first served system, which poses added challenges in correctly allocating services when some patients have been on a waiting list for more than two years.

How targets fuel a new hierarchy of care: emergencies, long-waiters, then everyone else

Despite the impressive efforts and successes of restoring elective activity after the pandemic, as well as the rise of innovative ways to provide care and promote collaboration among providers, we are still far from having room to breathe. In this context of significant mismatch between demand and capacity, the limitations of national targets that would encourage efficient management in a balanced system are laid bare.

A pertinent example of this is elective waiting lists, which have been the object of various targets to reduce long waits. The good intentions behind these targets are undeniable; no one should be made to wait for care for more than a year. In a system where demand is matched with capacity, such long waits should never be an issue. In principle, a sudden surge in capacity directed at these long waiters might be enough – at least for some trusts – to clear them. However, this is problematic for two key reasons: it fails to account for clinical urgency and the resources that must be reserved for the sickest patients, and it directs disproportionate energy to 2 per cent of the waiting list.

Previous experience shows that initiatives to address targets are incredibly energy-consuming for trusts. They may also fail to gain buy-in when they don’t match local clinical priorities. What we have seen at large trusts is that the backlog of elective diagnostics does not stand a chance in front of the volume of emergency and two-week-wait cancer referrals. As patients approach waiting targets, however, they are pushed to the front of the queue to avoid missing them. This is not solving the backlog issue – it merely adds another pressure point.

Perhaps more throughput-focused national targets, such as setting a maximum number of waiting-list per head of population, would be more effective while allowing trusts to decide how to manage their own waiting lists.

ICBs create an opportunity to focus on local priorities

If there is one thing that the pandemic has demonstrated about the NHS, it is that when empowered, trusts and local systems are pioneers of innovation and can rise to unprecedented challenges. From the London Ambulance Service, which partnered with the London Fire Brigade to deal with rising ambulance demand, to the Royal Surrey NHS Foundation Trust that partnered with a local private hospital to provide excellent palliative care despite the pandemic (NHS Providers, 2020), the pandemic bore witness to numerous examples of unparalleled collaboration and innovation.

There is an inevitability about some targets in that they reflect national priorities and are a way of tracking progress and holding systems to account. There is some evidence to suggest they motivate change and can be a catalyst for improvement. But the flipside is that blanket targets don’t take into account local need and they penalise providers that are otherwise making huge progress on elective recovery. They’re also not particularly good at motivating staff in a positive way—health and care professionals understand that targets are organisationally important, but they’re not always aligned with what professionals and patients think is important. If ICBs are to be held accountable for delivering on targets, it only seems fair that they should have a say in what the targets might be and it can be expected that priorities might change from one locality to another.

This should not be seen as a limitation, but as an opportunity. We think ICBs are the key for a more nuanced approach to designing and setting priorities that might catch two (or more!) birds with one stone: managing the elective backlog and addressing local need with highly relevant targets.

ICBs could set their own targets, that are in line with national priorities but refined to fit local circumstances. Local systems could engage their workforce and patient voices in agreeing what these look like. This approach still creates accountability and sets a direction for change (the point of targets) but also gets buy-in from the teams charged with meeting the targets—targets that reflect their priorities and what they see in their own practice.

It doesn’t have to mean a free-for-all or ducking difficult problems. National bodies can still ensure local systems are ambitious, hold them to account, and provide support and guidance to deliver change. Programmes such as GIRFT do this very successfully. Instead, what we propose would allow local systems to have more freedom to invest in novel care strategies to tackle their unique challenges. Importantly, it could be a mechanism to engage with, value and retain the workforce.

Of course, the counter is that differences will emerge across localities. But the truth is that this is the current reality, demonstrated by the charts above. And those differences would likely start to narrow if – and this is critical – ICBs are given time to flourish, work to meet local priorities and learn from one another.

About the authors

George Bachelor is Co-Founder and Director of Edge Health s

Lucia De Santis is a qualified medical doctor and Analyst at Edge Health, providing

For more information about Edge Health, please visit www.edgehealth.co.uk.

How IQVIA is optimising respiratory pathways to enable long-term NHS recovery

By Integrated Care Journal

As the NHS continues its recovery from Covid-19, IQVIA has been working with integrated care systems, with its analytics capabilities helping them to deliver on regional and national priorities.

The NHS has been significantly impacted during the pandemic and must prioritise workforce investment, COVID-19 recovery and a reduction in the backlog of care. To support patients, key objectives have been outlined in the NHS Long Term Plan and the NHS Operational Planning and Contracting Guidance. These objectives support the integrated care systems (ICSs) priorities to:

Enhance experience of care
Improve the health and wellbeing of the population
Reduce per capita cost of healthcare and improve productivity
Address healthcare inequalities
Increase the wellbeing and engagement of the workforce

IQVIA, a human data science company, has been working with ICSs to achieve these priorities as well as the overarching aims of the NHS. Through its Interface pharmacist team, a team of clinical pharmacists and nurses who support primary care and community health services, IQVIA can support with patient identification and treatment actions, therapy reviews, patient and clinical education and flexible capacity support.

Case study: Leicester, Leicestershire & Rutland (LLR) ICS

IQVIA were commissioned by LLR to deliver a Respiratory Optimisation Programme over a seven-week period. This clinical support was intended to ease some of the pressure caused by the backlog of care and allow vulnerable patients to receive timely support due by providing additional clinical capacity. Over the course of the programme, IQVIA were able to:

Identify opportunities for improvement, support efficient allocation of resources and deliver patient-centric services which improve access to medicines and optimise care.
Identify gaps in care, recognise patients at risk of adverse events and improve patient outcomes.
Provide skilled capacity to deliver best care at scale and address healthcare inequalities.
Provide mentorship opportunities to the multi-disciplinary team and support and sustain enhanced care.

IQVIA’s Interface pharmacists delivered 3,000 COPD clinic appointments across the LLR ICS, working with 71 practices – with 54 per cent of the pharmacy practices in the LLR ICS. Across these practices, 11,348 patients had a diagnosis of COPD recorded. 8,692 of these (77 per cent of the total) were identified as potential beneficiaries of treatment optimisation, and 7,420 of these patients (85 per cent) were invited to a COPD clinic.

Of those patients seen in clinic,

635 patients received an escalation to their current level of management
100 patients received a de-escalation of their current level of management
2,132 patients maintained their current level of management
1,119 non-pharmalogical interventions were made, including referrals for smoking cessation or pulmonary rehabilitation

Due to the pandemic and subsequent backlog in care, many of these patients had no recorded care process in the last 12 months. After the pharmacist clinics there were significant increases to these key markers, including:

A 96 per cent increase in patients who had a COPD review
A 171 per cent increase in patients who had their inhaler technique checked
A 212 per cent increase in patients with a CAT assessment

The seven-week support programme provided LLR with the additional clinical resource needed to assess and proactively manage patients with COPD. The increased capacity benefited the health and well-being of patients whilst the multi-disciplinary team were engaged with the review to provide ongoing, continued care.

About IQVIA

IQVIA utilises extensive data and analytics capabilities to inform clinical decision-making. To support and drive key advancements towards improving patient outcomes, IQVIA is at the forefront of unlocking the potential of NHS health data to realise future health improvements for the UK and deliver transformative benefits for the patients of today and tomorrow. IQVIA believes that the value of NHS health data is not in the data per se, but in the clinical decision-making it can inform. As a trusted partner to health systems and providers, we use our extensive data and analytics capabilities to transform health outcomes and deliver pioneering biomedical research within the 95 per cent of NHS Trusts who use one or more of our services.

Workplace discrimination and equality concerns driving NHS acute staff exodus

By Integrated Care Journal and Gabriel Blaazer

Almost a quarter of surveyed staff working for NHS England acute trusts stated in their 2022 Staff Survey that they intend to leave their role in the next 12 months.

Workplace discrimination and equality concerns are the most significant factors driving acute staff to leave the NHS, according to analysis of the 2022 NHS Staff Survey conducted by consultancy firm Lane Clark & Peacock (LCP).

In a workforce already plagued by burnout, stalling pay and low morale, the findings will come as concern for policymakers seeking to staunch and reverse the flow of acute staff leaving the NHS. The acute sector employs more than 850,000 full-time equivalent staff, 25 per cent of whom are Asian, black or another minority ethnicity, compared to 13 per cent of all working-age adults in the UK.

Among the diversity and equality issues highlighted in the NHS Staff Survey were: a lack of fairness in career progression and promotion (reported by one in eight respondents); discrimination from managers or other colleagues (nearly one in ten); discrimination from patients, their relatives, or members of the public (more than one in twelve); and a lack of respect for individual differences (almost one in twelve).

There was variation in staff responses based on their ethnic background. In particular, 17.2 per cent of staff from ethnic minority backgrounds reported experiencing discrimination from their manager or colleagues, compared to 6.8 per cent of white staff members. These findings are notable in light of recent reports documenting a pattern of racism and discrimination in the NHS.

LCP also looked at all the acute trusts across England to identify which areas most struggle with the diversity and equality issues named above. London and the East of England are the worst-performing regions, but the problem is widespread.

Source: LCP. Data source: 2022 NHS Staff Survey. Diversity and equality score is reported on a 0-10 point scale and is based on responses to four contributing questions. Acute trust catchment boundaries adopted from the Office for Health Improvement & Disparities. (Click to enlarge.)

Hotspots for staff dissatisfaction

There is a stark geographical contrast across England when it comes to staff planning to leave the NHS. Trusts with the highest percentages of staff intending to leave are overwhelmingly located in London and the East of England, while trusts with the lowest percentages of staff intending to leave are concentrated in the North West and North East and Yorkshire.

Source: LCP. Data source: 2022 NHS Staff Survey. Acute trust catchment boundaries adapted from the Office for Health Improvement & Disparities. (Click to enlarge.)

Natalie Tikhonovsky, Analyst in LCP’s Health Analytics team, said: “Our analysis reveals a grim picture of low satisfaction levels and higher staff turnover rates currently facing the NHS acute sector. Understanding what is driving this will be key to the success of the government’s new workforce plan and to the overall aim of reducing steadily increasing wait lists.”

Catrin Treharne, Principal in LCP’s Health Analytics team, also commented: “The next steps for improving the NHS’s organisational health could include addressing disparities in staff satisfaction levels between trusts and investing in diversity and equality efforts to foster inclusive workplace environments. By understanding the root cause of NHS workforce challenges and designing solutions to properly address these, we can improve not only workforce satisfaction in the NHS but also patient satisfaction and outcomes.”

Leaders call for ICSs to “subvert” health and care system

By Integrated Care Journal

Public Policy Projects’ ICS Delivery Forum event in Birmingham on Tuesday, 18 April, saw integrated care leaders from across the West Midlands convene for localised debate on the future of integrated care for the region.

“Ambition and partnership” are the central ingredients to successful integrated care, according to Danielle Oum, Chair of Coventry and Warwickshire ICB (pictured above). Oum was speaking at the Public Policy Projects (PPP) ICS Delivery Forum at the Library of Birmingham on Tuesday, 18 April, where hundreds of key health and care stakeholders, including ICS leaders, clinicians, local authority leadership and community representatives gathered for a day of localised debate and networking.

The ICS Delivery Forum is a series of localised events designed to monitor the progress, and help realise the aspirations, of integrated care. Throughout 2023, PPP is hosting Forums in: Birmingham, Manchester, Leeds, Bristol and London.

The setting for this Forum was the Library of Birmingham, a place described by Oum as a “centre of excellence for research, for learning, for creative expression, for health information.” In many ways, Oum said, this visible anchor institution epitomises the ambition and partnership a that should define an ICS.

“If integrated care is successful, it can totally subvert our model for health and care”

Oum used her keynote address to call for the NHS to be more “mindful” of the impact it has on local economies, emphasising the role of the NHS as key local employer to regions.

“If integrated care is successful, it can totally subvert our model for health and care,” said Oum, who stressed that resources must be “refocused and rebalanced” in order to target energies onto health prevention, early intervention and reducing levels of ill health and inequality.

ICS Delivery Forum — Hundreds of health and care leaders from across the midlands attended the Delivery Forum.

Following Oum’s keynote address, a series of panel discussions and case study presentations were provided to an audience of more than 150 local ICS, NHS and local authority leaders and community representatives. Key topics of the day included:

Developing partnerships to deliver services
Collaborating to optimise the patient pathway
Effectively addressing health inequality in the West Midlands
Developing a truly integrated workforce strategy

While topics may be familiar to many who will have attended health and care conferences, this Delivery Forum was unique in that it was entirely focused on the West Midlands region. “If integrated care is to be developed locally, then it must be discussed and debated locally,” said PPP Head of Content, David Duffy, who also stressed that, in the shadow of the Hewitt Review, it is vital that, now more than ever, that local leaders are given the necessary platforms to identify the challenges and opportunities in integrated care most relevant to them.

Also speaking was Tapiwa Mtemachani, Director of Strategy and Partnership for Black Country ICB. Emphasising the importance of partnership and of assets to transform care presented by the local community, Tapiwa Mtemachani, Director of Strategy and Partnership for Black Country ICB. Mtemachani emphasised the importance of partnership and prevention in bringing down stubborn levels of deprivation and health inequalities seen across the Black Country, which has the second most deprived population of any of the 42 ICSs in the country.

“There is a narrative that prevention is too costly, but prevention is how the system should be managing demand, how it can reduce costs and expenditure while improving outcomes,” said Mtemachani. Black Country ICB has been doing this through extensive partnership working with local housing providers, using their local reach to promote prevention and overall health promotion. “At fairly low cost, we have developed a health coaching model for citizens, in close partnership with Walsall Housing Group, with impact already visible for our citizens,” Mtemachani explained.

Other notable local ICS representation included Dr Ananta Dave, Chief Medical Officer for Black Country ICB, who outlined how ICSs can help optimise patient pathways across the West Midlands. Also in attendance was Former MP, Salma Yaqoob, who is now Programme Director for Health Inequalities for Birmingham and Solihull ICB and Shajeda Ahmed, Chief People Officer for Black Country ICB.

The next ICS Delivery Forum takes place in Manchester on 25 May . PPP will be publishing a full report of the key insights uncovered at the Birmingham ICS Delivery Forum. For more information on the Delivery Forum, please visit the PPP website.

Prevention, early access and health inequalities: Redefining place-based care

By Gavin Bashar

Gavin Bashar, UK & I Managing Director at Tunstall Healthcare, discusses the focus on prevention, early access and health inequalities and the need to use technology to redefine place-based care.

If the healthcare system is to are to re-define care and achieve preventative services that reduce health inequalities, it’s important to approach services both holistically and through targeted resolutions to specific areas of care provision.

Redefining place-based care

Place-based care has the potential to deliver multiple opportunities. In order to capitalise on those that are presented, it is important to first define ‘the place’ and what this means to people both providing and accessing care services.

When defining place-based care it’s important to consider the different demographic regions across the UK. There are disparities in the health and wellness of communities with different population characteristics, and differences in access to technology, health and wellbeing, and life expectancy should be accounted for.

By starting with place-based care, it is possible to approach issues around prevention and proactivity and the tailoring of care. This in turn will help care providers to combat health inequalities and improve access to health, social care and housing.

The implementation of ICSs

It is hoped that integrated care systems (ICSs) will drive real system change that removes silos that are currently placing barriers on delivering the most effective services.

Considering single accountability and each step of an individual’s care journey will empower us to support ICSs in their role. This will be further supported by real collaboration and integration across the system. If we address issues and demand earlier, budgets and funding streams can be allocated to the specific areas that need them.

The role of tech

Technology’s role as an enabler can move the prevention agenda forward, however it is only valuable if it drives sustainable system change. In order to integrate technology effectively, we must bring the right skill sets into our services to ensure they can deploy digital solutions successfully.

Technology can have significant benefits for citizens, particularly in terms of using data to provide intelligent insight to inform more personalised and preventative care. We should see the ongoing progress that’s been made around data privacy continue, particularly as future generations are now growing up in a digital landscape. This will lead to citizens being more comfortable with health and care technology, and having a better understanding of how they can be empowered to play a more active role in their own wellbeing.

For more information, please visit www.tunstall.co.uk.

News April 20, 2023

Working together at scale: FAQs on provider collaboratives

By Charlotte Lewis

Provider collaboratives represent an opportunity to transform health and care delivery while driving improvements in patient outcomes and lived experience. This supports the ambitions set out in the policy paper: Integrating care: next steps to building strong and effective integrated care systems across England.

Provider collaboratives are one of the cornerstones of the English health and care landscape.

As of July 2022, provider collaboratives are mandatory for all NHS trusts providing acute and mental health services. Many NHS community and ambulance trusts have also been offered the opportunity to take part and non-NHS providers may also be included where this will benefit patients and makes sense for the providers.

NHS England defines a provider collaborative as partnership arrangements involving at least two trusts working at scale across multiple places. Provider collaboratives represent a move away from competition to one of cooperation and collaboration – underpinned by the duty to collaborate in the Health and Care Act 2022 (the Act).

In summer 2021, NHS England published guidance to formalise the move to collaborative working, which sets out some minimum expectations for how providers should work together at scale in provider collaboratives. A supplementary toolkit provides further support on setting up collaboratives, including potential governance models.

Mills & Reeve share insights from their learning and experience of working with provider collaboratives up and down the country on what makes a successful collaborative – the honeymoon period can fade fairly quickly as you get down to the difficult issues.

Mills & Reeve have prepared 10 FAQs as a guide to the process of forming a collaborative.

1. Choose your partners carefully: who should you partner with?

The first step for providers is to work out who will form the collaborative. This will often depend on the purpose of the collaborative.

For example, ‘horizontal’ collaboratives usually bring together providers that offer similar services (e.g., acute hospitals or mental health services) whereas ‘vertical’ collaboratives tend to involve organisations that provide different services (eg, collaboratives bringing together primary care, community, local acute, mental health and social care providers).

Often existing relationships will make for a good partnership as you will have a shared history of other joint working or partnering.

There is no ‘one size fits all’ and providers should come together in provider collaboratives in ways which make sense to achieve benefits of scale, provide resilience and deliver system priorities.

Providers will also need to bear in mind how different types of provider organisation operate and take this into account when deciding how they will be treated within the collaborative and how this might affect the contractual structure.

For example, independent sector (IS) organisations might be restricted by their banking covenants from underwriting another organisation’s risk. Providers should therefore be mindful of these differences and work together to develop equity within the collaborative. This means giving each provider what it needs in order to reach a place of equality within the collaborative, as each provider is not necessarily starting from the same position.

2. Objectives: Do we need to define our priorities early?

Providers will need to consider the overall aims and objectives of the collaborative. This means thinking about the reasons and incentives that organisations have to enter into the collaborative in the first place, their ultimate goals and what they are actually seeking to achieve together. Be clear about your objectives.

For example, is the collaborative a vehicle for contracting, or are the providers looking to create real change and improvements to the service for patients?

Providers will also need to work out how place and provider collaborative arrangements interface, especially given that ICBs will be able to delegate functions and budgets to both types of partnership arrangement. Provider collaboratives will need to both agree objectives with ICBs and align priorities with place-based partnerships, as well as develop a shared understanding of their respective roles.

3. Capacity and complexity: How will the various collaboratives work together?

Providers are likely to be part of multiple collaborative arrangements and/or alliances which will perform different functions and operate over a range of geographic footprints including neighbourhood, place, ICS and multi-ICS levels. The complexity and variety of different partnership models within any single system is likely to put pressure on already overloaded leadership teams, clinical services and operational teams.

We have supported providers to develop cross-organisational support functions to pool resources and expertise in order to overcome some of these issues.

4. Governance: Be clear and transparent on your governance model. What do you need to think about when deciding on your governance structure?

Providers need to be clear and transparent on their chosen governance model. So, providers will need to agree on the voting and decision-making structure of the collaborative, and consider questions like:

Do all the providers have equal voting rights, or does the lead provider get more of a say?
Must the majority vote also include the lead provider, or can the lead provider be bound by a decision it has not agreed to?
In the event of deadlock, does the lead provider get the casting vote?
What are the processes for existing providers to leave or new providers to join the collaborative, and how should this be agreed?

Where a lead provider model is adopted (see below) careful consideration must be given to the interaction between, and separation of, the lead provider’s dual role as both provider and commissioner.

For example, rather than reserving all commissioning decisions to the lead provider, it might be better if these are dealt with by the collaborative as a whole, or even by a separate team instructed by the collaborative. This is where a hybrid model might be useful (see below).

5. Model: Form follows function but which model suits best?

No one size fits all and NHS England’s guidance is clear that it is up the providers to decide which model will work best for them in the context of their ‘shared purpose and objectives’.

The following guiding principles should however underpin the chosen model:

a shared vision and commitment to collaborate
strong accountability mechanisms for members
building on existing successful governance arrangements
efficient decision-making
embedding clinical and community voices
streamlining ways of working

Popular governance models:

Lead provider:

Where a single provider holding a contract with a commissioner, sub-contracts with other providers in the collaborative to coordinate service delivery and improvement. This model was common with the mental health NHS-led provider collaboratives.

Shared leadership:

Where multiple providers appoint a single person (or group of people) to fulfil key leadership roles across the collaborative – particularly the chief executive role – while maintaining specific leadership capabilities for each provider within the group.

Provider leadership board:

Where senior leaders from participating providers establish a joint forum to shape a collaborative agenda. The joint forum may operate with delegated authority to take decisions for the providers.

These models are not mutually exclusive, and Mills & Reeve have worked with a number of collaboratives on hybrid models.

For example, a lead provider model could still involve shared decision making and include a leadership board, enabling the lead provider to be aligned equally with the other providers by use of a partnership agreement. In our experience, this can help to create a more open and collaborative environment where all providers feel they can contribute and participate on an equal footing.

Increased powers detailed in the Act have opened up the potential to:

Enable collaboratives to take on functions and budgets from ICBs via delegation, where appropriate;
Allow trusts to come together via a joint committee to make legally binding decisions;
Facilitate provider collaboratives to take on more formal responsibilities from ICBs, including budgets and functions, via delegation agreements.

6. Financial risk and opportunity: How do you manage the risk and/or gain of a collaborative?

Providers will also need to plan and agree on how to deal with the financial risk and/or “gain” of the provider collaborative. In many collaboratives, any financial surplus is reinvested into the system in order to improve the service and ultimately, benefit patients. This means that individual organisations will not take a portion of any “profits”. Instead, the surplus is a saving that can be used as an opportunity to make improvements, buy equipment, or hire more staff.

Such risk and gain share agreements can support the idea of mutual accountability by ensuring fair impact and benefit of collaborative activities for all members.

7. Clinical mode: Do I need to scope out a model identifying how care will be delivered?

Clinical leadership should be at the heart of provider collaboration, with improving services and outcomes for local populations as the driving force behind the collaborative’s programmes. It is essential for the collaborative to prepare a clinical model in order to work out how care will be delivered in a better and more cost-effective way, in order to improve the experience of patients and staff. A detailed clinical model should set out exactly how the service will be delivered differently and will also help providers to see how the collaborative will work in practice.

8. Sharing information: Do we need to set up a data sharing agreement?

The success of integrated care relies on sharing information, so providers will need to be aware of the issues associated with competition and sharing information.

There are potential difficulties where the collaborative includes independent sector (IS) organisations because they must comply with various competition rules, such as not sharing commercial sensitive information or fixing prices. For multi-site IS providers, this presents a risk in terms of having to share patient and staff data or information with other organisations.

It will be important to agree what information needs to be shared with which organisations and to document this accordingly. For example, we have supported organisations to set up information flows and barriers in order to ensure that the right (and only the necessary) information is shared between the various organisations in a safe, legal and appropriate way.

9. Intellectual property: Do we need to include IP clauses in a collaborative agreement?

Potentially yes. Providers will need to think about the IP position, such as what will happen where a provider leaves the collaborative after developing or contributing to new ideas or concepts that have created useful IP. Will the provider be able to take this IP with them or does it remain with the collaborative? Can it be licensed?

10. Risk management: Balancing the organisational and collaborative’s needs

Accountability between providers is a key feature of a collaborative, and an important means of ensuring progress on shared objectives. Providers will be expected to support and contribute to transparency and mutual accountability.

Providers and provider collaboratives will need mechanisms to identify and monitor risk, and to ensure the governance arrangements they work through are strengthened – and not eroded or confused – as statutory system working develops. However, there is a balance to be struck between proactively managing the questions and risks which arise through emerging collaborative arrangements whilst also realising the opportunities stemming from provider collaboration.

Get in touch with Mills & Reeve for advice or support with your provider collaborative.

Join Mills & Reeve at the I ntegrated Care Delivery Forum in Leeds, on Wednesday 28 June.

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The Hewitt Review: key takeaways so far

By David Duffy

The eagerly anticipated Review into integrated care systems (ICSs), led by former Health Secretary Patricia Hewitt was published today, setting prevention decentralisation and cross government co-production as key priorities. What have we learned so far?

Former Health Secretary and current Chair of Norfolk and Waveny ICS Patricia Hewitt, was commissioned by Chancellor Jeremy Hunt last year to undertake a substantial review into the accountability, governance and oversight of ICSs. The 89-page Review, published on Tuesday, covers England’s 42 ICSs and makes a series of recommendations to enhance the autonomy of ICSs.

In the forward to her report, Ms Hewitt says: “Unless we transform our model of health and care, as a nation we will not achieve the health and wellbeing we want for all our communities – or have the right care and treatment available when it is needed.”

The Hewitt Review calls for ICSs to be given the time and support to succeed. The establishment of ICSs must not simply be another superficial reorganisation – and the Review acknowledges a growing policy alignment ICSs that will “last well beyond one parliament, government or minister,” giving ICSs the time and space to embed the new model.

Shifting power from the centre

The Review also outlines how growing acceptance of the ICS model from DHSC and NHS England should come with a drive towards decentralisation wherever possible. To realise the promise of these systems, the Review states that “national and regional organisations should support ICSs in becoming ‘self improving systems’ given the time and space to lead – with national government and NHS England significantly reducing the number of national targets to no more than 10 key national priorities.”

Central to providing ICSs with greater autonomy is to reset approaches to health and care finance. Accordingly, the Review calls for greater funding flexibility for 10 of the most mature and best performing ICSs, as well as for broader funding reforms to be “multi-year and recurrent”.

Commenting on this, Sir Julian Hartley, Chief Executive of NHS Providers, said: “The emphasis on improvement over top-down performance management is essential and we hope the NHS at all levels will commit to the cultural shift necessary to bring this about.”

However, Hartley went on to call for greater clarity on the responsibilities and accountabilities of the different system players.

“We worry that trusts and integrated care boards (ICBs) will struggle to work as equal partners while ICBs have day-to-day oversight of providers.

“We’re also concerned that some recommendations could add complexity and bureaucracy – for example, with auditing prevention spending and reframing the role of local government oversight.”

Cross-government co-production

Hewitt insists that, for ICSs to be successful, substantial reform is also required at the heart of government. Article 1.25 of the Review states that:

“Critically, all of us need to change. Local partners within every ICS need to put collaboration and cooperation at the heart of their organisations. NHS England, DHSC and CQC need to support and reflect this new model in the crucial work they do; and central government needs to change, mirroring integration within local systems with much closer collaboration between central government departments and other national bodies.”

Hewitt also calls upon the government to lead a “national mission for health improvement” to shift the national conversation around health promotion – this forms a central part of Hewitt’s drive to promote better health and wellbeing, rather than simply treating sickness. “To underline its importance, this could be led personally by the prime minister,” the Review states.

The Review also calls for the establishment of a central Health and Wellbeing Assembly with a membership that “mirrors the full range of partners within ICSs, including local government, social care providers and the VCFSE sector as well as the NHS itself.”

Shifting the dial on prevention

Hewitt makes a number of recommendations to embed prevention as an overarching principle for ICSs. This includes increasing the share of NHS budgets at the ICS level going towards prevention by 1 per cent over the next five years. While acknowledging that many systems will struggle with this adjustment, the Review insists that:

“An ambition of this kind is essential if we are to avoid simply another round of rhetorical commitment to prevention.”

The Hewitt Review also calls for a consistent national framework to monitor prevention investment by Autumn 2023, and suggests that ICSs should establish and publish their baseline investment in prevention by April 2024. Further, the Hewitt Review includes a recommendation to increase the public health grant allocation, which is central to enabling systems to drive forward their ambitions for the health of their local populations

Commenting on the Review’s focus on prevention, Mathew Taylor, Chief Executive of the NHS Confederation, said: “The focus on prevention is crucial for long term sustainability of both the NHS and more broadly to increase health and wellbeing of the population, and something for which we have long been advocating.“

Health inequalities as the primary objective

Recent research from Public Policy Projects revealed widespread acceptance among ICS leaders that reducing health inequality is the biggest priority for integrated care. However, with ongoing immediate pressures and a seemingly endless cycle of year-on-year winter crises, many systems have been unable to develop the long term population health strategies needed to bring down health inequality.

In arguing that action on health inequalities is far more than a ‘nice to have’, the Hewitt Review echoes PPP’s position that action on health inequality is itself the primary objective of ICSs and essential for the long-term viability of the health and care system.

Hewitt said in her review that: “I heard real concern that the transformational work of ICSs and specifically the opportunity to focus on prevention, population health and health inequalities might be treated as a ‘nice to have’ that must wait until the immediate pressures upon the NHS had been addressed and NHS performance recovers. That is what has always happened before, and must not happen this time.

“Prevention, population health management and tackling health inequalities are not a distraction from the immediate priorities: indeed, they are the key to sustainable solutions to those immediate performance challenges.”

Empowering ICPs

The Hewitt Review also suggests a number of measures to give greater significance to the role of integrated care partnerships (ICPs), including the establishment of a national ICP Forum to create direct communication between ICPs and DHSC and to make the ICP the primary mechanism through which preventative health policy can be delivered.

The Review also gives due consideration to the need for cultural change within NHS, local government and provider bodies. As stated in PPP’s report, Ensuring ICSs represent a partnership of equals, it will take time for the constituent parts of ICSs to become familiar both with each other and with collaborating across organisational boundaries.

Digital skillsets

There is also welcome recognition in the Hewitt Review that the lack of digital skills at all levels of the health and care workforce is a significant barrier to the success of digital and data-driven transformation. This formed a core recommendation of PPP’s ICS Futures, which calls for mandatory digital expertise at board level and efforts to increase the digital competency of the workforce more broadly.

Expanding the role of CQC

With greater autonomy for ICSs will come a greater need for flexible accountability and as such, the role of CQC, and how it can be enhanced to provide greater system oversight, is one of the key focuses of the Hewitt Review. In accord with PPP’s Ensuring ICSs represent a partnership of equals, the Hewitt Review calls for increasing expectations of CQC to assess the level of mutual accountability between partners within a system. This will include assessments on cultural change and system integration.

Section 3.87 of the Review states that: “CQC should take into account the extent of collaboration around organisational development and quality improvement.” This, the Review states, should be led by a “Chief Inspector of Systems” who should draw upon the multiple sources of quantitative and qualitative data available to CQC.