Building Neighbourhood Health: A Conversation with Nigel Edwards

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Transcript

Introduction

Katrina

Welcome everybody to today’s episode of the NAPC Podcast. I am absolutely delighted today to have in the room, Nigel Edwards, who is going to talk to us about all things population health, neighbourhood care, care models and drawing on this sort of vast experience. We’re gonna have a discussion about where we are, what works and how you actually get some of this to happen, most importantly.

Why Neighbourhoods Matter

Katrina

Nigel, you’ve had a front row seat on system transformation in health and care for decades. What draws you now to think that you know the focus needs to be on neighbourhoods and integrated teams that sit around them?

Nigel

I thought for a very long time that the sort of big error that Bevin made in establishing the NHS was there be so much emphasis on things being national and nationally determined.

Other NHS systems in in Europe have gone down a different path and have put much more emphasis on sort of the regional or even municipality sort of local level. Even some of our current ICB’s are other size of EU countries in population terms. So we still remain very centrist.

So I think the first lesson is that we need to be very clear what definitely needs to be determined nationally, do once. What’s in the category of adapt and adopt and what’s in the ‘Actually this is about local determination and needed to work it out’ and we’re massively confused about that.

So Spain, for example, has a single method for risk stratification across all of its 17 autonomous communities. We’ve probably got more than 17 in London, I would guess. Why would you not centralise that? Why is everybody doing data sharing agreements locally when they could be done nationally? And then there’s people doing things locally which doesn’t speak to the NHS app, which apparently is fine. So I think the first lesson here is we need much more clarity about what is local and what is national.

When we do this, we do far too much, which is national and for the local, we’re not clear, often not clear enough about what the design rules are. So that’s the that’s the first lesson I think.

The second lesson is that we’re also very poor at prioritisation and working out what we can actually do within the resources that we’ve got. My experience in other countries, which are sort of fiscally challenged like ours, is you’ve probably got space to do 5 or 6 things. You don’t have space to do 150, but that means locally, people really need to be very rigorous about actually working out what’s important and doing it.

And then I think the third lesson from internationally and particularly in the NHS is I think it’s called Hofstadter’s law. Which is everything takes longer than you think, even accounting for half status law, there’s just an elapsed time thing, particularly for those changes which are require changes in work processes or the establishment of new relationships. And I’m afraid that that history suggests that the people making policy have been very bad at understanding those three really important things.

Leadership, Culture, and Change

Katrina

Sparking so many questions for me in my head because the priorities things, so one of the things I observe endlessly is they talk about 150 priorities, but actually there’s only one and it’s called the UEC programme in most systems. And it’s actually about the edges of the flow through a hospital, it’s often not even about the flow in the hospital, but the edges of the flow between the two. And that seems to consume the vast majority of thinking time, clinical and managerial leadership type.

So I’m going slightly off script here cause what’s intriguing me is how you genuinely put some thinking into priorities and then take the resources that you have, both leadership and frontline delivery financial, but largely it’s people. And following through on doing something about those priorities.

Nigel

Yeah, I mean, it’s quite hard to develop a policy prescription to that frankly. I mean, it’s quite a lot of that when you look at the systems who do seem to be able to do this it is quite a lot about the quality of the senior managers and their ability to kind of create a bit of an umbrella over their local systems to say right, you know they have to deliver the UC agenda cause it’s indeed elective waiting, but they seem to purposefully also work on these – create some space – to work on these other issues and I don’t know if it’s easily bottle able formula for that.

And it’s of course quite a few examples that one might site. You know there’s sort of Jim Mattis and Glen Burnies and others of this world do often start from the advantage of systems are quite are kind of working already.

The difficulty, particularly for people already underwater where they don’t manage to sort of earn the space because all this is actually about the senior managers holding the line and saying no, actually we know what we’re really we are going to make a focus on neighbourhood health or population health or health improvement or whatever, you know or whatever our two or three current priorities are. We’ll fix your HC over here, but we’re not gonna let it drain out the things that actually are important for the longer term.

Relationships and Leadership Skills

Katrina

I actually think it does come down to local system leadership. So you’re sort of borough based, your municipal leadership as well, because I think it’s quite hard to have a formula from that on high. Again, I think that’s one of the sort of local you need local leaders and one of the things I observe about the NHS is that we seem to have completely dropped any sort of leadership development at any level. And I think that in order to deliver, albeit hostile, there’s laws as it’s gonna take longer than we think it’s gonna take.

So much of this is about the leadership at, I guess what you called the sort of municipal ICB level, but then actually I think it’s the leadership below that level, that’s critical. And it needs that adaptive, different style of leadership and for me the lever I don’t think we’ve been putting for at least the last five years, maybe is around developing our leaders, really putting investment into developing our leaders, which would allow them to think through that challenge of how you deliver urgent emergency care at the same time, there’s two or three other priorities and don’t drown yourself out with a spreadsheet.

Nigel

Yeah, absolutely. I was very struck as in a conversation yesterday, which the current acting chief executive made a very interesting observation, which was, you know, we got 11 local authorities we have to deal with to try and get our flow sorted out and some of that, there’s more than there’s several upper tier ones that we’re dealing with, but we’ve done our relationships and got a sense of common purpose. It’s actually meant we’ve managed to streamline all of our discharge arrangements between the different authorities and we know we have made significant progress on flow

That’s about long-term relationship building as well as the technical skills of leadership. So I think there’s something also about just slightly concerning in the current context. You know people in post for reasonable periods of time with the right skills to that relationships and not situation where the people that you’re dealing with think well you’re having these conversations with me, but I do know that you know and interestingly, can meet you up at any moment, pull you out of this meeting or distract, you know, distract you from the thing that we’re all agreeing on.

So, I think there’s a combination of soft technical skills, which sometimes we’re also. I think there’s been a lot of development of those over the period I’ve been in the NHS, you know, when I started that most management didn’t consist of any technical skills at all. It was all, but it was all about relationships. I think the relationship bit we perhaps needed to rebuild, but you need both of those things in place.

The particular risk here is that the middle managers in these systems see their job as defending the territory and the boundaries of their bit, rather than solving other people’s problems. So there is a quite a flip required in quite a lot of the standard and quite understandable sort of socialisation of middle managers have about exactly what their role is and how they relate to the rest of the system.

Implementation Challenges and Evidence

Katrina

A really good point, because I would say often that is the barrier that gets in the way. These poor people in the middle management jobs just get accused of being the block to any transformation and change. And by the frontline they get, you know, accused of managing the money too tightly and not understanding the real issues of being a clinician or a practitioner on the frontline.

So creating a permissive culture I think is another of the big strands that I see that’s changed this. I even hear chief execs and boards say to me, we haven’t written our strategy yet because we’re waiting for the guidance that tells me what needs to be in the strategy. So the whole permission to lead and to take on your role, since I think for me in that sort of leadership development space.

But it’s such a big culture to shift cause that’s silo piece and that you do what you’re told and you don’t do anything else. It’s now such an ingrained set of behaviours shifting that type of behaviour is not going to it’s probably in Hofstadter’s law as well because it’s not gonna change overnight. You don’t change your behaviour, you have to invest in shifting that behaviour when you’re doing it across organisation.

Nigel

That becomes particularly difficult, and so I think the over the next few months as we start to see what the shape of the new DHSC and the NHS England arrangements look like and the nature. There has been some attempts to try and reduce the number of targets and priorities, but there’s still very strong rhetoric of, you know, being tough which you kind of understand. But I think the challenge is if you want a neighbourhood based system, but you’re running a national service. It’s a paradox, right?

I mean, we’re gonna have a national plan for neighbourhood health. Well, how’s that work? We’re gonna have national, I’m gonna be tough on management, and we’re gonna dry performance, but actually, I want more standardisation, I want to reduce variation. But these are really subtle and tricky paradoxes that need to be worked through, right?

I mean, we don’t have the right level of standardisation. Absolutely. But you know, working out, which is the right? What should be standardised and what shouldn’t and you know and then doing the standardisation bit just and a very interesting example came up in the again in the conversation yesterday was a public engagement with Londoners says ‘We want a standard way of accessing general practice.’ It can’t be the case that you know every single practise has a different method. It all ought to be roughly the same, right? Which is fair. I mean, actually I’m not sure any other business which had half a billion encounters with the public would not have some form of standard method for doing it.

But just think about the leadership management and effort that will be required to do that and, you know, the subtlety of that’s going to be needed to work out what is important to standardise in that and what can be left to local practices. Very tricky and I just, I’m not sure we quite know how to do that. And again that’s gonna be 1 of the reasons why you know A) it’s gonna take longer than we expect and B it’s probably going to be, there’s gonna be some false starts and it will be a bit rough around the edges as we’re doing it and again we’re not very tolerant of that.

Decision-Making and Implementation Challenges

Katrina

I think that was what was running through my head, actually, as you were speaking as I think one of the other traps we fall into is thinking you can describe perfect and then a perfect linear path to get to it. And that is not what we’re describing here. And how does the system have the confidence to just get on and do something, even if we actually don’t know exactly what the end’s gonna look like because the things you’re talking about are huge.

Even an understanding of what you do once you know one single risk stratification system across the whole country is huge. You can imagine that burying large numbers of people for years. So how do we take steps onto a journey that we sort of vaguely know is going in this direction? But we’re not quite sure exactly what the right ones are and don’t just create paralysis, which is what I think. I observe a lot of paralysis, of waiting for the perfect answer.

Nigel

Yes, well, or sometimes the opposite, which is, rushing off and buying your own five year licence on the system that actually you know isn’t gonna work with anyone else’s. So we’re back to this question about what’s the right place to take the types of decisions we need to take and what are the right processes for making this decision. So, you know, if we go back to the risk stratification or data sharing agreements or that seems to me to be one thing where you know, following this first example, one would just go for stratification or segmentation, we’re gonna buy X. We’ll buy John Hopkins if you wanna use your own as well, that’s fine. But actually we expect all your data to come back to us in ACG’s, right. And we’d like to see your processes using it where possible.

And you could do that quite quickly. But we’ll probably set up a two year process to think about it. So I think being what clear about what’s central, how quickly do you need to make the decision and then actually just getting on with it probably is this something that needs to be thought about at all, all levels of the system.

Prevention and Population Health

Katrina

Just in my head at the moment, there’s a slightly more fundamental question as well as whether people is the evidence there. And do people really believe that if you enable people to improve their health through the full core interventions, everyone knows sleep more, eat better, move more meaningful purpose and connections, it will reduce demand on acute services.

Because everything we focused on in the last decade has been at the end of the journey on acute demand and I guess this thing that revolves around my head as I go around talking to people is it’s easy to say, but if you weren’t really talking at the heart of the matter, do we think that the evidence backs this up and that people believe if we shifted our focus to neighbourhood based teams, enabling people to live healthier, it will reduce demand on acute services. Because I think that’s what drives the constant crisis management, if I’m honest as well. But there isn’t really that belief there.

Nigel

Yeah. And to be honest, the evidence is partial, right? I mean it’s, it’s not bad in a number of ways. I think one of the things that we’ve learned and this, I don’t know if this is in people’s mind, is that where there is evidence. The question about our capability of replicating the approach that produces that is a bit of a worry, isn’t it? Because one of the very striking things with a lot of these interventions is if you only do 90% of it, it doesn’t work.

There’s a kind of Pareto thing, right, you’ve really got to do the thing with the active ingredient in it, that works and do it well to get anything like 90% of the result that is in the research ever since, right. So the skill of execution of these things, I think the also GK Chesterton once said if something’s worth doing, it’s worth doing badly.

You know, lots of these models don’t work well if they’re done badly, you know, they don’t sort of partly work. You know, you they do need skill and execution. And I think that’s probably one of the things that people have found out over the years with, you know, the replicability of many of these integrated care and multidisciplinary care team models is that they’ve often produced quite disappointing results, and that’s often because they’re just not being very skilfully implemented.

So I think that’s probably behind quite a bit of the nervousness is that, you know, people are, maybe a bit aware that, you know, while there is evidence, there’s quite a lot in this for all of this, putting the services in place that do deliver it, the culture shift amongst some clinician professionals who have a different view of sort of world view of these issues to be thinking more like that are all quite difficult to do and people have been through other types of attempts to implement new models of care, which often have not quite produced results that everyone hoped, but in some cases actually make things worse by creating additional demand that that that lies behind some of the nervousness, I think.

Starting Points for System Change

Katrina

So you walk into a system, Nigel, you do that every day at least every week and they they’re struggling with the complexity. Where do you start? What would you advise them? Where do they start?

Nigel

Well, I think the very interesting piece of work I did with NAPC sort of learning from your experience in this space is as you start with, you start with the frontline clinical staff and start to think about how they work and how you can help them work in more effective ways. That starts to build their team working, helps them to understand the, you know, the population health data that is available that can help them think about how they target their efforts to support them in designing some of the new ways of working in systems and processes and to some extent start bottom up.

Assuming of course you got a clear idea of what you think the endpoint in terms of outputs and outcomes is going to be. So you’ve got a story to tell about ‘this is where we’re trying to get to’, which is about improving population health and well-being, getting to be more proactive, being more effective at prevention, tackling inequality. So that high level vision. But the actual nitty grit needs to, I think, be a lot based on people learning by doing and building, you know, having the time and support to do some of this stuff at a much more local level than we’ve tended to do.

So, you know, you probably do need to get everyone together in the room and to do those sort of big workshop things. But actually that’s not where most of the action is. And I think we’ve had those big meetings and that often very not much happens in between them, but I think the just shift the focus so that more of us is about people in MDT’s having actual time to sit back and go well you know let’s try this new thing. Let’s try this new system, here’s a new member of staff we’re gonna bring in.

There’s all this evidence was on ARRS types roles, for example, both in this country and in the literature is, you know, the time and effort to do the design, to integrate new models of delivery and integrate new members of staff is quite significant. Generally, we don’t give anything like the level of support and time that people need to be able to do that. Then we’re surprised it doesn’t work as well as it might, and the people aren’t clear about what their role is and how they’re fit into the system.

I’m increasingly thinking that processes of local experimentation and learning, supported by people who’ve got change management and facilitation skills to help them do that local community practice just so that people don’t have to entirely invent new ways of doing things, combined with this clarity about what you’re designing and what are we going to mandate because actually we are going to have a single system of GP triage across the whole of the ICB or whatever you decided, I think that’s what I took from the some looking at the lessons from and the work in of the NAPC have been doing from other experiences in this space.

Hope for the Future

Katrina

And I guess the sort of final thing I want to ask is as we started with, you’ve been developing thinking on this and been involved with systems over many years as has I, is it different this time? Do you hold more hope that we might actually get on and shift and get some of this right? And create some longevity out of it this time round? Or are we just waiting on the next policy reform that reverts us again. More hope or not?

Nigel

I think there’s reason to be optimistic. I think more people who understand the importance of population health, how to make that happen, who get the need for a multidisciplinary, large approach to primary care and the centrality of primary care in delivering much of this gender of improved relationships and ways of working with local government, which also is reason to be encouraged.

The thing that makes me more pessimistic is, first of all, you know, these types of big changes do require resources and we’re short of both people’s time and money to support the change process. The second is the experience of these types of plans and some of the people who are involved in developing them is that they tend to be very ambitious in terms of having very large number of things to do and actually we need to focus, and they also tend to be poor on how it’s going to be done.

Which on the upside means that there’s the scope for people develop local solutions. But on the downside, given the culture that we were talking about earlier of people waiting to be told, is perhaps a real concern about whether we actually have the mechanisms to make some of these changes happen and I think there is sort of fundamental question about where decisions need to be taken and an instinct to try and centralise decision making to tell people what to do to which stifles initiative, reduces everything to the lowest common denominator, often introduces a culture of overly aggressive performance management, and if not actual bullying, and that tends to too often focus on the short term objectives around emergency care and electives rather than the longer term goals of improving population health.

Closing Summary

Katrina

Thank you. I think we could probably discuss this matter for days on end, not just today. I thought I’d just try and pull out a quick summary of the sort of top five things I’ve heard you say cause they’ve really helped me and I think that first thing about really understanding what you do once and what you do local is absolutely critical.

We’re getting it wrong on both counts. We’re doing things that should be done local once, and we’re doing vice versa. We’re not just nailing the stuff that should get sorted out once, so the energy probably in the centre needs to be at that much more macro scale and what do you do once and what you do local.

I love the example that even in a complex environment with multiple local authority boundaries and potentially provider boundaries, you can work your way through the relationships, but it takes time and it needs continuity of leadership.

This is going to take headspace and time for the frontline teams and not underestimating it. I mean, I go further than that. I hear that it’s just not even seen as acceptable to have conversation with each other like you have to just crack on. So changing that cultural shift that says this is about time, headspace and that that will need skilled coaching facilitation to overcome the barriers is another point.

Then there’s something for me about the sort of middle tiers of management that we have trained to take instruction and then deliver and hold to account to the point of very extreme performance management both ways, that needs some really thinking about how do you shift to a more adaptive style of leadership and an adaptive emissive culture.

But I guess the final bit is where you ended that and I’m with you on this there does seem to have been a perceptible shift in the people seeing this, as the long term solution for both an affordable and a better quality and better outcome based National Health Service for this country. So that gives hope that that sort of is gone from the zealots at the front saying why are we doing this differently to a much more mainstream set of thinking, if only we could find the time to do it, and that in lies the leadership challenge.

Nigel, thank you very much and thank you for helping us keep on track on a subject that I know I can meander on for some time. So thank you very much.