Jim Mackey: Removing barriers to place-based systems of care

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  • Posted:Tuesday 01 March 2016

Jim Mackey, Chief Executive of NHS Improvement, discusses the process of developing Sustainability and Transformation Plans, and draws attention to the support available to local leaders.

This presentation was recorded at our event Moving towards place-based systems of care on 1 March 2016.


I just want to talk a little bit about the STP process. I’ve spent all morning doing the usual, talking about A&E and bad performance is etc. so it’s been a nice light relief. And there’s a bit of a theme in what I'm going to talk about and how we reconcile the short term versus the long term. You’ll see in month nine quarter three results a couple of weeks ago, pretty awful, as I predicted when I was here a few weeks ago.

A&E performance for January when it’s announced next week which will be pretty awful so yeah the data Q3 was 90%, it’s about 88% at the end of January. So those of you that are involved in those services will know it’s pretty tough out there.

And the point of this is that shouldn’t make us avoid the long term stuff. So I know it’s really tough but we have to take the opportunity in the STP process to really have a go at the long term changes that we need to make.

So a bit of a reminder on this, Simon might have covered some of this this morning. When we did the plan and gain, so kind of post SR running into Christmas, when we were trying to work out what we’ll do, what we wanted to do was to have an institution based quite short and dirty sort yourself out plan, so some of you have done that already, so submission’s the 8th Feb but then really try and take the opportunity in the spring to think about the long term. So hopefully we’ll get to a point where the money is more manageable next year, without getting rid of the deficit entirely but it looks like a bit of a miracle for next year, but we’ll do our best.

We’ll then take a breath and really think about the long term. So we think about it from a political point of view, this is the year you’re going to possibly make changes and then after that we start lots of other political changes that make it more tricky again. So really what we wanted was quite quickly agree a footprint, get yourself sorted out, get the leadership in place. You probably already know what the big things are that you need to change what you want to, if it’s a reconfiguration or if it’s going down a more integrated route or there’s merger and acquisition activity or whatever, you probably already know what they are. So by the time we hit July we’ve got a good plan, and we’ve maybe done a bit of conditioning and socialising of some of the change, so from a politics point of view we know that will impose some of this change off. If we’re still dancing around the handbags next January, it’s just not going to happen because we’re going to be running straight into the next political cycle where really we’ve got almost no chance of pulling off these things.

There’s absolutely a load of technical stuff we’ve got to work out when we’re doing this, because this is all a bit amused. So it would be nice if we came up with a snappier title than footprint first of all but how do we make sense of it, how do we work the money, how do we make sure the money actually flows in a way that’s supportive of this, how do we understand some of the misaligned incentives in the reimbursement system? But in the conversations I’ve had over the last couple of months relating to this the problems are largely in the non-technical area. So there’s a couple of places where it’s not really that easy to work out what the footprint is but not many. Their problems are where there are terrible relationships, and there’s quite a bit of that. There’s an understandable problem around have you got vested interests? So something absolutely is barn door obvious in that it needs to change, but it affects you and your institution, how do you get over that? Because this is about trying to deliver for the broader good of your community.

There’s definitely an issue of freeing up sufficient capacity and head space to think about the long term when you’re up to your armpits in day to day muck and bullets. And then there’s this thing about the NHS is really good at dodging the difficult stuff isn’t it? We can all think about the really obvious changes that should have been made 20 years ago, 15 years ago, ten years ago etc. we’re very good at finding a reason not to do that because it’s just really tricky and it’s going to be really difficult, some of it will involve pretty nasty consultation probably etc.

So I would urge you don’t dodge it again, just genuinely have a go, we’ll not be able to make all the changes you all want to make but it will definitely not be able to make it if you don’t ask.

And I think there’s a really hard thing about how we work and do what we need to do for our institution but how you get your head around working in a system, recognising that you need different governance, arrangements, recognising that that might mean your institution can't win everything because it’s not right, you can't, it’s not possible etc. And then how we’ll help people through some of those changes.

So there’s a load to techy work went on to say what are our footprints. It’s surprisingly difficult in some parts of the county to work out what the footprints are. There’s some really obvious nice natural communities that have existed forever and everybody understands where they are. Then there are some that are really actually just quite tricky. So we’ve been through that process there, they’re all agreed, there’s one or two areas where people still feel slightly uncomfortable. And importantly there’s some really big providers that actually serve multiple STPs and we need to work out how they’re linked together because we’re in danger of causing huge problems for some very strategically important providers, so we’ll have to work around that.

Some of the STP footprints build on success regime areas where you might have heard already about some of this today where there’s already established processes now and they’re starting to gather pace after a bit of a slow start. And then you’ve got places like Manchester and other areas where there’s a well-developed devolution plan and there’s a very natural footprint there. And as part of that, as a regulator what we’re trying to do is to say, “Let’s put some resource into that maybe people into that” and then we get off the pitch and we’ll agree at an aggregate level how that works with that system. And then there’s some level of devolution within that area where people look after themselves, so again we’re not trying to fix national rules into a system where there’s maybe good evidence that you’ve worked out a local solution within your system.

And this shouldn’t distort or disrupt or get rid of other collaborative arrangements that are already in place, I would urge you to just try and continue with them as well through this process.

We’ve obviously got to deliver on the five year forward view, so this isn’t about just trying to find something new to deliver upon, we’ve got to deliver on these things obviously so there’ll be a bit of a national flavour and hopefully a local flavour. So again I would urge you to not go and invent new distraction activity so problem X when actually you need to solve problem A to F. So I know some of you will have seen this before, the NHS again is really good and finding new problem to solve and avoiding solving the ones that we need to solve now.

I think this is really all about relationships and getting the conditions right at the beginning, being honest with each other, having an understanding of what the challenges are that you think you’re trying to tackle, be an honest and constructive way and making sure you aren’t avoiding the difficult stuff or you’re trying to hide behind a problem when actually it’s really obvious that’s something that needs to be resolved.

And we will be just kicking the tyres a bit on making sure everybody is actually involved that needs to be, so it’s genuinely a whole system thing. And as I said earlier on, if we’re going to get a result this is about relationships, it’s not the technical stuff, it’s not whether we did the modelling right, it’s not whether we spent the right number of weeks trying to work out whether it was 44 or 43, it’s about whether you can all work together and we’ll get the leadership right. Some of the calls I’ve had over the last few weeks have been around I thought I was going to lead it and now somebody else is going to do it and often that’s about let’s make sure they don’t lead it because they’re definitely going to deal with this issue and let’s find someone who will allow us to dodge it, so we’re onto that, you can smell that 100 miles away. And make sure you don’t have a leader who’s just clearly not up to it, or isn’t in the right frame of mind etc. they’re generally kind of self-selecting and deciding on how you’re going to run through the list on Friday anyway, at the minute that looks like there’s broadly half of our providers either NHS providers or local authority chief exec and about half are commissioners, there’s no contrivance in that, we didn’t set a target for how many had to be providers and how many had to be from an acute provider etc., they genuinely have just kind of emerged.

And we will see some when we go through the list that we don’t think can do it and we’ll have a conversation about how we get to the place that we need to get to to make sure we take this opportunity.

So as I said earlier on it can't be about protecting institutional interests. Some places have come to us and said that if we’re really going to do this, this individual control total thing doesn’t really work and some of you have said control totals don’t work altogether anyway which is understandable but for places that may be either a success regime area or the Devo areas where we need to agree a different mechanism.

We haven’t got any flexibility of how it works at a national level but we can aggregate and dis-aggregate to suit the local circumstances. Don’t get stuck in the weeds on this, so don’t get distracted with you’ve got twelve weeks for a process, don’t spend eleven weeks saying, “Who’s going to do it?” Don’t spend ten weeks trying to work out who’s going to run the PMO, where the PMO’s going to be based, should they be on this site or that site etc. So that’s absolutely going on, so let’s not pretend it’s going on. It’s a completely wasted effort, let’s just as quickly as we can get to the point of what the issues are and how we’re going to fix them.

In some places the answer might be a new organisational form but don’t start with the new organisation form, work out what you’re going to try and fix first. There’s a lot of people come straight back and say, “I need a new payment mechanism, let’s get rid of PBR” or, “I don’t like the GP reimbursement system, I don’t like the GP contract” whatever, that happens all the time. This isn’t about fixing those things so let’s work out what the problem is you’re going to fix. If at the end of this one we’ve done everything there’s a need to do those things we’ll get to them but this isn’t about changing some of those things.

And it’s really important I think to boil this down to the four or five critical things and try and identify how you’re going to crack them and what the limiting factors are and make sure you’ve got a reasonable chance in the time that you’ve got, So don’t start off with 26 things that you’re going to try and fix in quite a short space of time.

You’ve probably heard already today about ACO development stuff so I'm not going to labour on that, it is the answer in some places and some places are now very close in getting to the last awkward bit of when you take the final leap it does mean it’s quite a big change for individuals, it does mean there’s a change for what job am I going to do in the future? What does this mean for my institution etc. etc.? We’re not expecting the country to be absolutely covered with ACOs in the coming year but it’s absolutely barn door obvious in some places that it’s the thing to do, there’s been a lot of energy spent on it already, I would just urge you if you’re in that place really go for it and try and tip yourselves over the edge.

And I think there’s a bit of a lesson in recent weeks for when we’ve snatched at a structural solution where we’re thinking about the problem and the risk. So at Cambridge all the people’s contract for example, there’s one that looked nice and trendy at the time, we all read about it in the HSJ, I was one of those people who read about it and thought I don’t understand how the hell that works and where the risk sits etc. and that’s absolutely what’s happened. So again think about what you’re trying to do, you’re looking after people, you’re looking after your population, don’t rush into some new institutional form without thinking it through properly and understanding the risk.

Finally don’t avoid the tricky stuff. So if you remember anything from today don’t avoid the tricky stuff, you know what it is, if you’re finding it difficult to talk about it we’ll help you talk about it if that’s what you need but try and get yourselves in a room and get on the table what the tricky stuff is in your patch. Don’t wait for someone else to tell you the answers, so again there’s no-one from NHSI or NHSE going to turn up and say, “Here’s the answer”. We might have to in the last couple of days with a process if we’re not careful, but we don’t know enough about your patch to be able to do that safely so try and take the opportunity and really don’t try and stitch each other up. So have seen, again a bit of the usual if we can construct it in this way it means they won't have a chance. I’ve had conversations with people where the leadership’s been decided without the main provider actually being involved in the conversation. It’s absolutely really blood ridiculous. So please don’t do it and if you’ve done it feel ashamed and go home and sort it out.

So we’ve obviously got a tough year ahead, we’ve got a lot to do with the 16, 17 money. We’ve got roughly 1.18 billion to fix about a 3 billion problem. As we were talking earlier on, so the answer might be a kind of Tommy Cooper fez and fizzle stick and all of that, but we need a better plan than that for the coming year. The reason it’s so hard now is because we didn’t really have a plan going into this year.

So we recognise money’s tight. There will be a second year of the transformation fund and we’re working on how we give systems and institutions more certainty as to what that will look like. So in magnitude and what you would have to do to earn it and that’s got a long time to be able to fix that properly. From today if any of you have ideas as to what you would like us to do with the second year of the transformation fund other than send it all your way, send us an email and we’ll find a way of having a conversation about it and we were thinking earlier on about I think first of all giving people the certainty of knowing there is a year two, so everyone doesn’t fall off a cliff after the first year, that might help.

Maybe there’s something about incentivising how we squeeze out 15, 16 to get to the right place, that might help. There’s certainly something about you’re definitely not going to get the second year of the transformation fund if you make a complete mess of your STP process. It’s a really big opportunity so really think about that.

And performance has to be improved in the coming year. When we get the rules out on largely the abolition of fines at the end of the week for 16, 17 and getting rid of some of the noise around contracts and stuff. We’ll also be trying to agree with people how much their performance will improve in the coming year and release the transformation fund for 16, 17. That doesn’t mean everybody hits all of the standards overnight because performance is so bad even I would accept that’s not possible. But there is something about making a lot of progress in the coming year and letting that flow into the next year to finish the job. We’ll work out a way of getting you some certainty about year two.

You definitely need to invest in partnerships and relationships and just on this partnership thing and the collaboration thing, there’s a load of misinterpretations of what this means. That doesn’t mean you never disagree. It doesn’t mean that you just skip around holding hands all the time and everybody’s lovely. A good partnership, a good collaboration is how you handle the disagreements and how you fix them. You’re not doing the job if you’re not finding things to disagree about. So if you’re feeling awkward because you’re going through these processes and have difference of views it’s absolutely fine, it’s normal, that’s what you should be doing. If you’re going through a process and everybody absolutely loves each other and you think you’ve got nothing contentious to solve in your STP go home and feel ashamed. You’ve got things you’ve got to fix. So have a good think about it.

And then just make sure your plans are credible. So a really good plan that you can't deliver is not much of a plan. So really have a think about whether what you’re setting out to achieve is actually deliverable full stop and within the time available.

And there are some places that actually the problem is there’s just a lack of energy, so how do you generate some energy and support and momentum into that system that will actually get you where you need to be?

There are some that will really struggle between NHSI and NHS England and we’ll work out how to help. So we’ve got a load of support offerings, I’m just going to skip through this. I mean I think my view would be our best support would be to not get in your way, so we’ll do our best to not get in your way. If we do need to help you we’ll help you. And usually in a good old NHS way help means you’re going to get bollocked. So let’s try and not get into that position and do what you need to do.

Then as part of that if we are getting in the way just shout, drop me an email or Simon an email or whatever and we’ll try and find a way of fixing it. It’s really messy at the minute so it’s really quite easy to think you’re doing something that’s helpful and then by the time it hits you it’s actually seriously unhelpful, so if we are doing something or saying something and there’s guidance comes out and actually contradicts the sort of thing that you’re trying to do, again shout and we’ll try and deal with it.

So I'm going to close and we’ve obviously in the coming year got to deliver the core money and access and constitutional standards, there’s nobody got a pass out on these things, it’s going to be hard to get there from where we are now so we’ll try and agree reasonable trajectories for people but if your STP process is - that would be lovely, but I really don’t want to do the ED standard anymore - it’s not going to get agreed, so don’t waste your time.

Long term success really does require us to think beyond our organisational boundaries and it’s really hard and I think when I found that hard in the past to try and think of those people out there that you’re looking after first and then work back and think about the institutional requirements and impact. We do need quite a lot of work on a strengthening collective system leadership at different levels to make sure that we’ve got the best chance of success. And this isn’t an end, it’s the start of a process so it’s a way of crystallising what you’re all working on and grappling with the day to day. We’re genuinely a start of an effort to try a number of things off the ground and over the line. We really must invest the right amount of time into getting there and it will change over the next few months. I think the idea now actually feel quite different to when we kicked it around in October, November of last year.

Finally this is absolutely a big chance to do what you think you really need to do, so I would really say if you do think your answer is you need to do X, Y or Z absolutely this is the time to do it. You will definitely not do it if you don’t try, so make it really hard for people to say no, really have a go.


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