Amanda Sullivan, chief executive of Nottingham and Nottinghamshire ICB, tells Emma Wilkinson how she hopes data will be the key to addressing health inequalities and improving efficiency.
Emma Wilkinson: What are the unique characteristics of your integrated care board (ICB) area?
Amanda Sullivan: We’ve got every type of community – rural agricultural, small towns, and quite deprived. We’ve got the inner city, and then we’ve got very affluent areas as well.
That’s where the place-based partnerships and the primary care networks (PCNs) are so helpful because they’re more attuned to those things but within a strategic framework. The partnerships are well-developed because we’ve got a track record of collaboration, which we’ve been able to build on and accelerate.
Data is a strong point for us, and we’ve done a lot to develop it. We are our data. It’s starting to show some differences with our population health management approaches.
EW: ICBs have been in set-up mode for a year, getting structures in place. How have you found that in Nottingham?
AS: In many ways, we were fortunate because we did have all the structures in place before we went live in July, and that’s helped us.
One of the reasons we were very keen to get our transition arrangements clear was because of a boundary change. Bassetlaw was a clinical commissioning group (CCG) on its own, aligned with South Yorkshire. Then, as of the first of July, Bassetlaw came into the Nottinghamshire system, which was coterminous with the county council. Given the importance of integration, aligning the local authority and ICS made a lot of sense.
The transition arrangements were important to us so that it seemed like one team rather than, you know, being added at the last minute. There was relationship-building to achieve that because we’ve merged six CCGs into one in the Nottinghamshire system.
EW: When it comes to improving outcomes in population health and health care, how do you feel that has been going?
AS: We’ve tried to think about having three buckets of activity. So, there’s managing today and today’s pressures, and then there’s thinking about making tomorrow better, which is health outcomes. And then there’s the system development piece, which is more of the cultural development.
To make tomorrow better, we have an outcomes framework, which has been developed locally across health and care. We’ve done a lot to build our data and intelligence, so we’ve got a granular understanding of where there are differences in health outcomes and health inequalities. And it’s then thinking about what we need to focus on through a different lens than simply the perspective of treatment activity.
EW: Can you give an example?
AS: Over winter, we were concerned about the rising cost of living and the impacts of fuel poverty on the population’s health. So we supported our place-based partnerships to develop those really broad partnerships so they can act as one to meet people’s needs.
We used our data capability through a public health lens and looked at the measures we could use to map fuel poverty. They matched the fuel poverty areas, usually deprived areas, with people with long-term conditions. And then, the GPs, the voluntary sector, and the PCNs could target people at very high risk.
It was offering a whole range of things. Some of it was health – making sure they had their vaccines and checking they had all their treatment plans to manage their conditions. Some of it was signposting into schemes like food banks, vouchers or financial advice so they could get access to benefits.
At the system level, we supplied each place-based partnership with the data for their areas. And then they worked with their council colleagues. The schemes did vary slightly in different districts, depending on whether it was a district council. But regardless, it made quite an impact.
For example, in the mid-Nottinghamshire area – Mansfield and Ashfield, where the old coal fields are -there’s a lot of deprivation. They think they saved households around £140,000. That’s by giving them advice and things like classes where people could go and get a slow cooker and make some food to keep warm. It’s using data in a population-specific and partnership-specific way so we can tap into community assets and bring together partners differently.
And collaboration happens at the system level as well. We’ve taken more of a shared approach to registers and things like that. We’re also making sure that we’re not making inequalities worse.
Then the other thing is that this new arrangement has given us a broader look at people’s mental health. The additional roles in general practice, social prescribers, for example, have been really helpful.
We’ve been doing what we call Green Blue social prescribing activities and working with local charities.
Green is about open spaces and having activities where people can go to boost their confidence. Perhaps they’ve been socially isolated, recovering from an illness, lonely, anxious, or depressed.
The blue is the water, and again, there’s a charity – they do things like paddleboarding. So it’s a much broader collection of things to help health and wellbeing
EW: What about tackling health inequalities? There is obviously quite a lot of crossover between improving health outcomes and tackling health inequalities, but is there anything specific you’d like to mention on inequalities?
AS: Yes, we’ve got an integrated care strategy, and it has three principles: prevention, integration and equity.
That’s different to the NHS universal service. We’ve got a very detailed map of all the differences in health and the health inequalities across various outcomes because of the data that I talked about. We are much clearer now than we were a year ago because we can look at the nature of the inequalities at a granular level. We can look at some of the drivers of those inequalities – some might be healthcare related, but a lot are wider determinants.
Alongside the mapping, we’ve got a health inequalities innovation fund, which is £4.5million, and we’re in the process of allocating that.
And then we’re doing things like we wanted the accelerator sites for the Core 20 plus 5. And each of our place partnerships has got a plan, which helps to tackle inequalities in their area. We’ve started with the most severe and multiple deprivations where people have got a number of things going on. They might be homeless, drug abuse, mental health problems – a whole range of issues.
There’s quite a big issue with that in the city of Nottingham and also the old coal fields. We’ve commissioned some primary care enhanced services around that, and the place partnerships are doing a lot of work.
EW: What about the financial position?
AS: We have submitted a balance plan this year. It’s going to be challenging to deliver it.
EW: We know that budgets are really strapped. Is there something that you’ve worked on when it comes to value for money or productivity?
AS: We have a dashboard – a system control centre dashboard -so you can see what’s happening in real-time, or pretty much real-time. The different data feeds in every 15 or 30 minutes. We brought the data together – ambulance, acute, community services, social care and discharge – and it shows us where things are inefficient so we can take action.
Having a common dataset means we can see in real-time where the actions need to happen. That provides really good building blocks for a more productive and efficient system around flow, unlocking a lot of other things.
Discharge is a big area of focus. Priority is around delayed discharges, and we’ve done a lot on that in terms of looking at our pathway, our capacity for discharge, home support, working with councils, and getting integrated discharge or transfer of care hubs up and running.
EW. What about the NHS supporting broader social and economic development? I’m assuming the NHS is a huge employer within the area. Do you have any infrastructure projects you can talk about?
AS: We’ve got something called Care4Notts, in which different work is done as a system instead of individual organisations. We’ve had over 700 apprenticeships through that.
And we’ve had over 10,000 people who have been to career events or gone through work experience and so on. We’re trying to grow our own talent and get ourselves on a more sustainable footing from a workforce point of view.
We also have a partnership with the universities and other public sector organisations, which do help around the skills pipeline agenda. And then we have a devolution deal that’s just going through with the plans for a combined authority – Nottingham and Derbyshire.
EW: What about the workforce situation more broadly? What are your plans?
AS: We’re probably very typical in terms of workforce challenges and shortages in some areas.
We are developing a one-workforce approach. We don’t have it yet, but we are developing it so we can do much more of a shared approach to recruitment. We’ll help staff move around and be more mobile around the system, which we hope will retain people.
The collaborative has priorities such as local talent management and retention. And then, the ICB will do more of the whole system and longer-term planning.
And, of course, we’ve got local government colleagues and primary care as well, which we mustn’t forget.
EW: You mentioned primary care, there. What’s your view of primary care?
AS: Primary care is obviously hugely important. And it sort of is the bedrock. We’ve got some really excellent primary care and, like everywhere, we’ve got some areas with staffing challenges. We are seeing more and more activity in and around general practice. We’re doing well on ARRS recruitment, which is helpful in a more holistic, place-based partnership approach. But it is under a lot of pressure. It has sustainability challenges. So we do have a lot to do.
With those things in mind, we developed a primary care strategy to get a sense of purpose and hope. And that is aligned with Fuller. We’re developing a forum with the PCN clinical leads and place-based partnerships as well. We’ll take that forward a bit more to have a purposeful primary care implementation group. And that will become more inclusive in terms of pharmacy and dentistry, and so on. We’re thinking about primary care in its broader sense.
EW: How would you rate your current engagement with primary care? Has that mainly been through PCN connections?
AS: Yes, they’ve tried to develop those leaders. We’ve also got our medical director, and that’s a new functionality that wasn’t there before. And we have clinical leaders who’ve got responsibility for the primary care development side of things as well.
We also have locality teams aligned with the place-based partnerships, and they know the practices really well. They’ve got ongoing day-to-day operational relationships with the practices. So it’s strategic and operational.
EW: You mentioned it briefly before. Are there any steps you’re taking specifically in light of the Fuller stocktake and primary care? Are there any development plans there?
AS: Yes, we have an integration director in the ICB and a system development unit. That’s a small group of people working very actively to develop the different bits of the architecture in the system. Some of them are directly working to support the development of the places, and they’re very close to general practice.
We supply a lot of data to them. They can access our dashboards, and we have a system analytics and intelligence unit, which is available to them.
EW: Is there something you would pick as a particular focus for you as we move into the next year?
AS: Yes, it’s probably dealing with the pressures and resetting some of that regarding demand and capacity across the whole healthcare system. That’s particularly in urgent emergency care, but some backlogs built up over COVID in other areas, such as some long-term conditions management and mental health.
In our first year, we spent quite a lot of time developing the integrated care strategy, and we’re in the final stages of developing the joint forward plan, which is the NHS response to that. That’s how we will work differently, particularly around integration, prevention and equity. So our priority is to make sure that we do the things that will make a difference.
EW: Finally, where do you hope to be this time next year?
AS: I hope next year that we deliver our plan as much as we can, operationally and financially. It’s challenging with things like industrial action – there are a lot of variables to manage within that. I hope we succeed in doing more of the UEC reset to take the pressure off the pinch points there. We are well on the way to recovering our services.
And we’ll continue to build different ways of working, embedding the health inequalities work and delivering on our joint forward view. So, making sure that we’re focused on today and, at the same time, actually starting to turn the dial on the health outcomes.