Integrated care boards (ICBs) in transition: leading change across the NHS landscape

Nick: Hi everyone and welcome back to our In the Spotlight series where we bring you stories and insights from industry leaders. I’m Nick Kennell, a partner at Gate One, and today we’re joined by Dennis Carlton, who’s an experienced leader in healthcare transformation working across integrated care systems. Dennis, it’s fantastic to have you here with us today.

Dennis: Thanks Nick. And it’s a real privilege to be here on one of your insight sessions. So, I’ve worked in the NHS now for over two decades, nearly quarter of a century. I started as a physiotherapist and worked in hospitals and private healthcare and elite sports for 10 years. But then I moved into what I do now, change and transformation and strategy work about a decade ago and I really love it. I love the challenge of working across multiple stakeholders, organisations and execs to build a consistent narrative and strategy. And then the bit that I really like doing is then working with the clinical and operational teams to make that strategy a reality and then see the fruits of our labour, the help that we can put to patients and residents.

Nick: Oh fantastic and great experience to be able to draw over this conversation. Dennis, thank you. And today what we’re going to be focusing on is ICB is the integrated care boards and the transformation they’re undergoing, both in light of the recent changes from an NHS England perspective and also the broader changes and transformation needed in the system. Just to start with, what are your thoughts on all the kind of change and uncertainty in the air and what this means for ICBs and their leadership teams?

Dennis: So from a structural and policy perspective, there certainly, certainly is a lot of change at the moment in health in the UK. Since the announcements in March about us, the ICBs having to cut their organisation in half and the abolition of NHS England as well. But whilst the structures and the organisational form is in flux, our core mission of improving patient care, improving the health of our population, helping our residents to live longer, healthier life stays the same.

So I think the challenge for ICB colleagues and wider colleagues within health is to try and avoid getting distracted by the noise as there is much uncertainty and stick to that core purpose, because that’s the thing that’s not going to change, no matter what happens with the structural changes. So I think it’s going to take a lot of resilience. We’re going to need to be able to prepare, to be agile and adapt and shift as we get more and more top down policy changes. But if we focus on that core purpose, I think we’ll be able to get over these challenges like we have done in the many restructures before. And I think, even though it doesn’t feel like it now, as of any challenge, this will be an opportunity.

The sheer scale of the changes that are being asked means that we’re going to really fundamentally have to look at who we are, why we’re here and how we fit in with the rest of the complex NHS landscape. So I think it is an opportunity to really look at what our value proposition is as an ICB, what our core competencies are, how we fit in and add value compared to the rest of the NHS landscape. So I hope, and I’m sure we will come out the other side of this with a leaner, more focused organisation that will be able to deliver on that core purpose at least as well, if not better than we were beforehand.

Nick: That’s really clear. And I think that point around core purpose is it points, isn’t it? There’s so much transformation in the system for patients that needs to happen. And you referenced a quarter of a century of work in healthcare in the NHS. Transformation in the NHS is notoriously challenging just because of the number of actors and the number of ways it can impact patients. What do you think is the difference between successful transformations in the NHS and the initiatives that maybe fall flat or don’t quite deliver that transformational benefit for the patients?

Nick: I didn’t like it when you say quarter of a century. I know I said that. That makes me feel really old. Right so, given my job, I’ve done a lot of thinking about what makes a programme successful and what makes it fail. And I think I’ve landed on three core themes, which I think is true in health, but it’s probably true across other sectors as well, and they are clarity, commitment and culture. So if I start with clarity, I think in health and in transformation, we are often really good at jumping straight to describing how we’re going to deliver something and what we’re going to. And we don’t spend enough time of clarity, of purpose and why we’re doing the transformation. And that I think if we ignore that at our peril, because it’s really important that we can articulate to our teams, to organisations and to individuals, the purpose of what we’re doing.

Because change, by its very nature, is new, novel, innovative stuff that could quite easily be seen as a burden or something extra to do on top of the day job if we’re not really clear up front of what the purpose is. And that clarity of purpose is a real Important thing for the success of the programme. I think they’re moving on to commitment. I think this is particularly true in senior leadership. If you’re the exec, sponsor or SRO of a programme, you can’t do that from the sidelines.

You need to be committed to working from the front, hand in glove with the programme team. A big part of that commitment is helping them to manage the risks and issues as they come up, help with decision making. I think commitment to help moving decisions forward even when there may not be consensus, is something that’s really key. And then the final one is culture. This is often underestimated, both in terms of its impact, but also how long it takes to make the change in culture again.

Nick, you’ve probably seen it yourself in many different programmes. I see so many plans that are brilliant at describing how we’re going to deliver the new bit of digital toolkit or the new operating model. And 90% of that plan is on how we’re going to get the bit of kit in. And then there’s a cursory week or two on the end of how we’re going to do the behavioural cultural change and we kind of tick the box and miss the point. The real success and the benefits will only come if we make the behavioural changes and cultural changes after we’ve done the actual transformation. And so I think underestimating the importance of cultural change, do that at your peril.

So in summary, I think the key kind of ingredients that I’ve kind of landed on over my time is commitment, clarity of purpose and the cultural changes and putting enough effort into that.

Nick: Yeah that’s really, really helpful and really interesting. Couldn’t agree more on the culture point. The number of Gantt charts you see where there’s just a culture change and a block line that goes across the bottom that doesn’t have anything in it. Knitting that together where you’ve seen like really effectively, if you’ve got any kind of examples you could spotlight of the real success stories that we can all learn from and build from.

Dennis: The one that probably sticks out in my head the most that I’ve done over the last few years that I’m particularly proud of is the delivery of two community diagnostic centres in the patch that I work on. So community diagnostic centres for those not in health, they’re pretty self descriptive. They’re centres based in the middle of our community that deliver diagnostics so you can get scans, blood tests, X rays in a centre that’s right in the heart of your community. And that’s got many benefits. It’s more convenient because it’s closer to your home, it’s away from the hospital.

So that’s good because the hospitals are really busy, so any activity we can move away from hospitals is good. But also, ironically, hospitals are not the best place for sick people. So anything we can do to move care away from the hospitals is also better for patient outcomes. And then also, because we’ve got all the diagnostics under one roof, we can do more innovative pathways, such as what we call test bundle. So rather than coming back multiple times for all sorts of different tests for your diagnosis, we can do them all in one appointment, under one roof. But the kind of ingredient that makes it stick out for me in terms of why I’m proud of it and while it’s successful, links back to my last answer of right up front. We spent a lot of time on the clarity of purpose and the why. This was a really big, important programme for our patch. It was multi million pound programme, important financially, but also really important strategically. So we wanted to be really crisp on the purpose and there were many drivers for that.

But the one that stood out was having an impact on health inequalities and access to diagnostics. So we knew that, like many systems across the country, the access that you have to diagnostics can be dependent on where you live and what your background is. And in my patch, like many, if you’re from a more deprived background, you have worse access to diagnostics than if you were in a different area. And so we really wanted to try and make an impact on that. And so that informed our decision to put one of our centres in the heart of a really busy shopping centre in one of our most deprived communities. It was an old shopping centre from the 1980s and that was a really difficult decision. It wasn’t the easy thing to do, but it was the right thing to do. We could have easily put it somewhere else with existing estate, done it quicker, cheaper and easier, but we knew that we wanted to hit our main purpose, so it was right to do the harder thing. And I think that kept us true throughout that programme. It was a really complex, difficult programme. Like anything like that. We had fallings out, we had decisions that we didn’t all agree with, we had risks against our budget and our timelines, but by having that purpose up front that we were all grounded in, that helped us get us through those challenges and make it a success.

And we delivered it on time, in budget. We’ve done over half a million tests and the vast majority of those are from those more deprived backgrounds. And so something we’re really proud of. And I think the key ingredient was us all having that key purpose to be grounded in.

Nick: Fantastic. Super example. And you got your own back on the quarter of a century comment by calling the 80s old, which is, as an 80s child, I took that heart. But no, that is a fantastic example about the points you made around the purpose and the why. That’s very much an example of the leftward shift that we keep hearing and talking about in terms of looking to the future and where the kind of ten year plan is going to take us, where policy is going. What things are you most excited about in terms of the direction of travel and the transformation opportunities ahead?

Dennis: So I think it’s linked to that, actually, Nick. So I think there’s two bits that I’m excited about. One is the move to neighbourhood model of healthcare, which is all about that left shift. And I think the second one is an enabler to that, which is the increasing shift from analogue to digital, which we’re going to need to do much more of in order to make neighbourhood health a reality. So neighbourhood health, for those that are not in health, what that means is moving away from what we traditionally do in health, which is very medicalised, very reactive. We’ve got some brilliant, super specialist people who are very good at, when you get sick, knowing exactly what to do for that disease and manage it once you’ve actually got to that crisis point in a hospital.

Neighbourhoods is about shifting that and moving to much more of a proactive, holistic approach where we try and catch and identify people at risk of getting sick early so that we can proactively manage you so you don’t get sick or you don’t get as sick as you would have done before. It’s about bringing that closer to your home. So in your neighbourhoods and joining up various different teams, so joining up your GP with your hospital doctor, with your mental health clinician, with your community practitioners, so that they’re looking at you as a whole, as a person, rather than just as a disease that we need to treat in the short term. And that really recognises the fact that we know only 20% of your health outcomes are impacted by health interventions.

The vast majority, the 80%, are not because of what we do as a health intervention, they’re due to wider determinants such as where you live, the amount of green space that you’ve got, your diet, the amount of exercise you do. And Neighbourhood Health recognises that and brings together the various teams to be able to look at you holistically. And I think that’s something that’s really exciting. And then just from the digital enabler to that, that means many things. That means being able to share information across those teams more seamlessly. So rather than having to go in and tell your story to 10 different practitioners would have shared your information where appropriate, so that you only have to tell that story once and you have joined up care from across various different teams. It also means that you don’t have to have lots of unnecessary diagnostics.

I see it all too often where someone has had a test, that test result hasn’t been shared from one organisation to another because we aren’t able to. And therefore we have to have a repeated test, which is a waste of time and money and resource. So sharing information will help to prevent that as well. Move from digital hangouts also means making it easy for you to book appointments, to be able to book online, driving everything through an NHS app so that you can manage all your healthcare admin via an app like you do for most of your other life admin. And then it also means putting into interventions where necessary to help clinicians on your direct and indirect care. And that’s not about moving, taking the human part out of your care, it’s additive to that. It’s about actually quite the opposite.

It’s giving clinicians more time to be in front of patients because they’re not sat behind a computer doing admin and stuff like that. I think the neighbourhood health model and that shift left and then also the shift from analogue to digital next.

Nick: Fantastic. That’s really helpful, Dennis. Really clear and some, yeah, really interesting. Really interesting and exciting opportunities for change for ICB leaders and healthcare leaders listening, who may be feeling a bit overwhelmed by all of this. The scale of what we’re describing and the, you know, some of that uncertainty we’ve discussed. What would your key piece of advice be for helping them stay focused on what matters most through this?

Dennis: I think I’d give the advice that I’ve been giving to my team since the recent announcement, which is keep calm, carry on. It links to what I said. If we can be grounded in the core purpose, which is improving health and lives of the people that we serve, that’s not going to change. No matter what happens around us. If we can not get lost in the process and the endless meetings and the endless strategy shifts and focus on why we’re here, that, I think, certainly for me, keeps me grounded when it’s feeling difficult and feeling really uncertain. I think also don’t lose sight and continue to focus on building and maintaining relationships.

That’s something that’s really easy to kind of let go of when you’re going through quite challenging times. But actually sustainable long term changes built on those relationships and I think they’re going to be more important than ever with the stuff that we’re going through from a professional point of view, but also from a personal point of view, it will make it much easier to get through these challenging times with these strong relationships intact.

And then the final bit, I’d say Nick, is just prioritise change is delivered by doing lots of small things well rather than trying to do everything slightly badly. So I think prioritise focus on the things that you think are going to make the biggest impact on that core purpose.

Nick: Brilliant. Well, thank you so much, Dennis. Couldn’t agree with you more on those, those points. It’s been great to hear your insights with us today and to our listeners, we hope you enjoyed this In the Spotlight episode and we’ll see you next time for another spotlight conversation. Thank you.