Jim Mackey: Developing local leadership as systems with accountability for population health

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Jim Mackey, Chief Executive, NHS Improvement gives a keynote address at our conference, Learning from new care models here and abroad, on 3 October 2017.

Transcript

Northumbria’s got about a half a million population, about 10,000 staff interest and about 1100 volunteers without all that which you know the system would fall over without now, and the big thing is the level of integration which started before my time, twenty odd years in the development and a huge OD process over that period.  Now the trust is one of the few still in surplus, still delivering the constitutional standards rated outstanding, soft one etc.  so that bits easy, but when you think of the accountable care bit and working with a CCG, the CCG has a deficit and that’s the big problem now about how we re-orientate everybody to think about how it’ll fix this thing together. 

We use the FT model as the catalyst for the public accountability bit and the work with the council has really helped develop public accountability in a different way there.  Everything’s as integrated as it can be, so when colleagues are getting uptight, especially the lawyers about conflict of interest, and who’s working for who and all this, ignore them. So a test for me often is if we’re in a room having a discussion, you can’t tell who’s working for who and it actually doesn’t matter.   

So a little bit more detail about the level of integration, it’s just gone to a new level so the council chief exec is actually the director of delivery in Northumbria.  Their deputy is the accountable officer in the CCG.  You can’t do this and day to day, do the day to day stuff is what people say to me all the time, but you’re only going to be able to do the day to day stuff if you’re actually doing these things, they’re completely interlinked.  

The big thing at the minute is, this thing about you can play at system work, you can all love each other, you’re SDP successful because you’ve met each other and, for the first time and you can say who each other are, but then you revert to contractual process and kick lumps out of each other, and they’re seriously contradictory processes.  So, make sure you’re actually not doing that.  I get held to account every Sunday morning when I go to see my mother, who blames me for every problem in our local system and she really couldn’t care less about who’s paying for what, she couldn’t care less about whether something’s a social care issue or a healthcare issued.  Frankly, none of us could really probably explain it or pass a test to say this is where the lines are and this is who pays for what.  

So success factors are really about trying to understand that you’ve got to create a climate for this thing to work. It takes time, you need time together.  Often this is about small incremental changes.  Don’t dodge the hard stuff, so there’s an elephant in the room about money, or a service configuration, or behaviour, talk about it.  So don’t allow yourself to contaminate the bigger piece by avoiding the difficult stuff, but try and find things to agree upon rather than find things to fall out about because there’s always going to be plenty of them.  

There is something about trying not to get into trouble, so you’ve got more freedom to do this if you’re in shape on the money and performance.  So try and get into that place, and generally try not to seek permission. So whenever you seek permission, you’re given somebody else the ability to say no.  Try to just get off and find your own plan and do as much as you can.  You really need to understand what your population needs are and everyone’s a little bit different, there’s a kind of common thread there about the elderly and the demands of the elderly, but if you’re in a system where your biggest problem today is about you’ve got a big chaotic community, for example that’s consumed a lot of mental health resource, understand why that is and create a plan that deals with it, don’t just lift everything off the shelf of you know this year it’s all about emergency admissions or something else, get into the data, understand from talking to the population about what the issue is for your patch.  Get a clear plan together, be able to measure what you’re trying to do and if it doesn’t work, change it.  Don’t get locked into having to do that forever.  Make sure the money is on the table and you’re being transparent about it because to not do that’s really corrosive and damaging.  

And importantly, really importantly, I think the thing to remember is, if you don’t engage with the public and staff, you’re going to play the wrong game.  So really try and create the time and the mechanisms to do that, and when you’re in that room on a dark January night with a load of people in one of your villages or towns and they’re holding you to account, what’s the benefit for them?  What’s been the point of this thing for them?  What can they see and experience as service users in the future?  And for me, that demonstrates the accountability it is to them rather than us.   

So I’m happy to take questions now, Chris.