Introduction

As we move into unchartered territory, 7i Group has been keeping abreast of new developments, trying to unpick what this sea change means for industry and the NHS. What will collaboration look like? How will the ICSs evaluate the value of new therapies and technologies? Who will be the key influencers?

7i Group investigated Greater Manchester as a case study. Whilst many ICSs are scrambling to make sense of the new structures that are being put in place, Greater Manchester (GM) has had a head start of sorts and took charge of a £6 billion spend on health and social care in April 2016.¹ What, if anything, can we extrapolate from GM devolution to help our understanding of future ICS structures and decision making?

Collaboration and leadership

With the movement from competition to collaboration, the NHS will now talk about ‘places’ and ‘neighbourhoods’, but currently there is no blueprint for how this will be set-up.

For Greater Manchester, leading the way in this venture, there were incremental steps in their set-up and planning. By October 2016 a new partnership had been agreed, including the performance and delivery board, finance executive group, transformation fund oversight group and quality board.² Over the next two ears population health plans were published, followed by cancer plans and Healthier Together business cases to standardise acute and emergency care.³

In the early years of devolution, The Greater Manchester Partnership Board sought to galvanise partners across all parts of the GM health care system, reinforcing shared identity to unify separate health and social care organisations continuing to experience their own individual statutory duties, regulatory requirements and local organisational pressures.⁴

A report published two years after the devolution of Greater Manchester titled ‘Devolving health and social care: Learning from Greater Manchester’ indicated the requirement for greater cohesion in order to drive a complex set of change programmes and detailed how structures and cultures had to evolve over time to accommodate this. GM had to emphasise that they were not simply setting up another strategic health authority by emphasising the role of local government as well as “encouraging the bottom-up-system wide empowerment through distributed leadership within the neighbourhoods”.⁵

As of August 2021, ICSs will be working across their partner organisations to align their CCGs and providers, planning activity, workforce and finances.⁶ NHS employees have had more time to digest and understand the concept of ‘collaboration’, but this example does highlight potential attitudinal stumbling blocks along with the impact of misunderstandings or potential misalignment of new partner’s organisational goals. Whilst those working within higher levels of the NHS have been embedded in organisational change, there is a question mark over how much of this has yet to be filtered down to lower tiers.

Leadership dynamics are likely to vary in each ICS, depending on historic power structures, with some localities taking on shared leadership roles and others remaining reliant on dominant trusts to ‘take the lead’. There are examples of trust leadership shifts within Greater Manchester, one involved a neighbouring trust being invited to take leadership over an underperforming trust, recently rated CQC inadequate.⁷ There are also examples of new collaborative relationships forming as a result of the coronavirus pandemic, which required NHS staff and services to work in new ways across primary, secondary and community care.⁸ Understanding these new leadership models, channels of influence and system structures will be important to drive any future decision making. Newly established collaboratives will naturally require a bedding in period before information and ideas are more freely shared and undoubtedly local politics and cultures will impact ICS ability to lead complex change projects in the short term.

Priorities and goals

Greater Manchester have released a document⁹ on the improvements made since 2016. They have sought to bring in measures in line with the national average for England, falling in line with the objectives set out in the long-term plan. Each ICS will need to set-out specific measurable goals and mechanisms by which they will contribute to the narrowing of health inequalities over the next five to ten years.¹⁰

These goals will inevitably vary across each ICS given the obvious variations in population, population density and public health issues. In addition, each local area will be facing different challenges across the whole system or pathway in terms of resources, efficiencies, quality or patient experience. Understanding the system from end-to-end will help industry and the NHS understand where new innovations can potentially add value.

For Greater Manchester some of the key initiatives since 2016 include: improvement in healthy babies/ reduction in still births; addressing specific CQC inspection concerns through local support and collaboration; earlier cancer diagnosis review and development of rapid cancer assessments; tackling smoking and implementing programmes to improve the consistency of acute, emergency, surgical and cancer care across the region due to specialists being spread too thinly across the region.¹¹

The success of GM devolution on health and social care is still being evaluated, but there has been evidence of progress in many areas. For example, more people being supported to live well for longer, specialist centres saving more lives and services increasingly fitting around patients’ lives.¹²

The role of other key influencing local bodies:

The Academic Health Science Networks(AHSNs) agenda is to drive adoption and spread of innovation across all areas of healthcare provision and population health.¹³ It is unclear what their role will be in the new structure, but given the government’s commitment to innovation, they could potentially represent an influential avenue at a local and even national level. For example, in 2020, the ASHNs supported national programmes for the early detection of eating disorders, improving diagnosis of ADHD and lipid improvement, many of which started as local initiatives that were subsequently rolled out nationally.¹⁴ ASHNs, such as Health Innovation Manchester, have supported the adaptation of health and care services in response to the COVID-19 pandemic, aiding the provision of care and the protection of patients and thus demonstrating their potential influence in driving innovation within local economies.

Primary Care Networks (PCNs) have been described as a key building block to the NHS long term plan and hence will continue to play an integral part in supporting primary care managed conditions.¹⁵ In 2020 there were seven national service specifications outlined for PCN involvement: structured medicines reviews, enhanced care in care homes, early cancer diagnosis, anticipatory care, personalised care, cardiovascular disease finding and tackling local inequalities in health. Within Greater Manchester primary care networks have been fully aligned with the integrated care system structure, with a focus on further mapping community pharmacists to existing neighbourhood structures and their 62 primary care networks.¹⁶ Several benefits for engaging with community pharmacists have been identified by GM and they envisage greater pharmacy involvement in triaging patients and health promotion and prevention.¹⁷

Health and Wellbeing Boards (HWBs) are a formal committee of the local authority charged with promoting greater integration and partnership between bodies from the NHS, public health and local government.¹⁸ Within recent months much of the Manchester Health and Wellbeing Board’s focus has been around the COVID-19 enhanced response area plan to identify areas of concern relating to COVID-19.¹⁹

Outside of COVID-19, key priorities include: Getting the youngest people in the community off to the best start; improving people’s mental health and wellbeing; bringing people into employment and ensuring good work for all; enabling people to keep well and live independently as they grow older; turning round the lives of troubled families; and one health and care system –right care, right place, right time.²⁰ It is currently unclear how they will align with the new ICS structure, although the Manchester Health and Wellbeing Board appears to be playing a pivotal role in identifying areas requiring a unified approach and supporting neighbourhood collaborations.

According to NHS England, clinical networks continue to focus on complex patient pathways using an integrated, whole system approach. Reducing variation in practices and services, encouraging innovation and providing clinical advice and leadership.

What can we learn from Greater Manchester devolution?

Whilst interesting to deep dive into a case study for examples of successful collaborative working and to understand some of the challenges around implementation, it is difficult to fully extrapolate to other areas. Localities that are currently undergoing ICS planning are surely turning to areas such as Greater Manchester for inspiration and best practice ideas, but the reality is that each region will develop their own local structure and system. For industry this means fully understanding each local environment, developing communications and engagement strategies that are fully aligned with local needs and priorities. Understanding local influencers, new stakeholders and local definitions of value will be critical in supporting patients and the NHS in adopting new innovative services, medicines and technologies.

References

1. https://www.gmhsc.org.uk/wp-content/uploads/2018/05/Population-Health-Plan-2017-2021.pdf
2. https://www.gmhsc.org.uk/wp-content/uploads/2018/05/06-Governance-Review-Proposals-SPB-19.01.2019.pdf
3. https://www.transformationunitgm.nhs.uk/case-studies/healthier-together-2
4. https://www.gmhsc.org.uk/wp-content/uploads/2018/05/06-Governance-Review-Proposals-SPB-19.01.2019.pdf
5. https://researchonline.lshtm.ac.uk/id/eprint/4651753/1/devolving-health-and-social-care-learning-from-greater-manchester.pdf
6. https://www.england.nhs.uk/wp-content/uploads/2021/03/B0468-implementation-guidance-21-22-priorities-and-operational-planning-guidance.pdf
7. https://www.gmhsc.org.uk/wp-content/uploads/2020/03/Taking-Charge-is-Working-in-Greater-Manchester.pdf
8. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/05/C0449-covid-19-deploying-our-people-safely-v1.2.pdf
9. https://www.gmhsc.org.uk/wp-content/uploads/2020/03/Taking-Charge-is-Working-in-Greater-Manchester.pdf
10. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf
11. https://gmcancer.org.uk/the-plan/
12. https://www.greatermanchesterca.gov.uk/media/1131/gm_prosperity_review_baseline___devolution_review___november_2018_.pdf
13. https://www.england.nhs.uk/ourwork/part-rel/ahsn/
14. https://www.ahsnnetwork.com/about-academic-health-science-networks/national-programmes-priorities
15. https://www.kingsfund.org.uk/publications/primary-care-networks-explained?gclid=Cj0KCQjw6NmHBhD2ARIsAI3hrM11V4jvhfnYiwBEW82OFqJO69U86iGhbAOjmGI4QuoMzVvQYgwfbDAaAj9gEALw_wcB
16. https://psnc.org.uk/greater-manchester-lpc/wp-content/uploads/sites/118/2019/06/Primary-Care-Networks-Part-Three.pdf
17. https://psnc.org.uk/greater-manchester-lpc/wp-content/uploads/sites/118/2019/03/NHSE-PCN-Manchester-GM-pharmacy-slides-FINAL.pdf
18. https://www.kingsfund.org.uk/publications/health-wellbeing-boards-explained#next-steps-for-integrated-commissioning
19. https://democracy.manchester.gov.uk/documents/s25095/June%202021%20Manchester%20enhanced%20response%20area%20Plan.pdf
20. https://secure.manchester.gov.uk/info/997/committee_membership/6024/the_health_and_wellbeing_board

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