Beyond the challenge: moving into delivery

I published my state of the system report, entitled ‘Turning challenges into opportunities’ in March 2023. This was intended as an honest assessment from me, as the chief executive of the Integrated Care Board (ICB), of the state of the health and care system in Lancashire and South Cumbria.

I wanted to produce a follow-up report to give you an update on our progress over the past 12 months and to explain what we have been doing to tackle the not insignificant challenges we continue to face. My report is intended to complement the annual report and joint forward plan, by providing a less formal narrative around the work that is taking place across the system and give my honest reflections of where we still need to achieve more.

Our vision has not changed. We want to have a high-quality, community-centred health and care system by 2035. We want to focus on ‘well care’ rather than ‘sick care’ by prioritising prevention, wellbeing and early intervention. This means more care delivered in the home and community throughout a person’s lifetime. In order to achieve this vision, we need to do three things – transform care in the community, reconfigure acute clinical services and improve quality through using the resources we have at our disposal in a better way.

As an ICB we need to commission sustainable, affordable, integrated clinical services that provide improved outcomes while making sure that people receive care in the most appropriate setting, which means bringing some services into the community and closer to people’s homes. This includes services for mental health, learning disabilities and autism where it is so important that the number of people who are provided beds outside of Lancashire and South Cumbria is reduced.

We need to improve primary and community care in all places and local neighbourhoods, working in partnership with the voluntary, community, faith and social enterprise sector, while also making the best use of all our secondary care services and infrastructure.

The ultimate aim is to improve the health and wellbeing of our population, and a key element of this is trying to keep people out of hospital unless it is absolutely essential. Therefore, we need to develop a system that offers support to people to avoid hospital admission in the first place, or that promotes early discharge from hospital into the community or into intermediate care settings.

“In order to achieve our vision, we need to do three things – transform care in the community, reconfigure acute clinical services and improve quality.

We will need to integrate care in the community to help people stay healthier for longer, caring for them by preventing ill health, managing long-term conditions, supporting recovery from periods of intensive care and, of course, providing good care at the end of their lives. And by continuing to push a population health-driven approach we will keep trying to reduce health inequalities. The fact that where you live can have such an effect on your prospects of a happy and healthy life is unacceptable and we want to do all we can to change that. Things we can do include multi-disciplinary teams of partners working together in local areas with a real understanding of the people living in their communities and how to support them either at home or remotely using the latest technologies.

It has been said before but the fact remains, we need to shift towards prevention and early detection of health conditions. Part of this means tackling and improving the conditions in which people are born, grow, work, live, age and die.

As well as the population we need to support our staff. An integrated staffing model across NHS, primary care and social care will allow staff to work flexibly across the system where and when they are needed. As well as supporting some of the more fragile services in our clinical networks, this should improve levels of employee satisfaction.

Ultimately we want to develop a health and care system – including all NHS services and other partners such as local authorities and voluntary sector – that operates as a true system, making the best decisions to support people’s health as if it were one single organisation, with people at the centre of our decision-making and services designed collaboratively with the public.

I know all of this sounds ambitious. It may sound pie in the sky to some people. But I didn’t come to Lancashire and South Cumbria to put sticking plasters on a creaking system and hope everything resolves itself. I’m here because I want to make a difference.

I said last year I was excited to get to work and I haven’t lost that enthusiasm. It is strengthened every day.

There is no point just trying to tinker with a system that isn’t working. In the last report I explained how life expectancy in Lancashire and South Cumbria is lower than the national average, health inequalities have worsened since the COVID-19 pandemic, we have more emergency hospital admissions than other parts of the country and babies born today have a healthy life expectancy that is lower than the expected state pension age of 68. That is simply not good enough.

So, we have to be ambitious.
 

Kevin Lavery

Chief executive
NHS Lancashire and South Cumbria Integrated Care Board

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Last year, I described a system approaching a cliff edge that needed fundamental changes to avoid falling off. I outlined some of the financial challenges we were facing and how these were a symptom of the way our system is configured.

I explained our opportunity to steer the car away from that cliff edge and towards opportunities to make a difference to the health and wellbeing of future generations across our region. And while we are still a way off and that cliff edge is still visible, we are starting to turn the steering wheel and programme the sat nav to point us in the right direction. There are a number of areas that we have been working hard in to drive towards our vision of developing a high-quality, community-centred health and care system by 2035.

This work includes...

Avoiding hospital admissions following a fall

NHS providers are working together with local authority partners to run a falls service, attending thousands of calls, to ensure vulnerable people get the most appropriate support in the right place.

The service helps reduce discomfort and stress of those who have fallen in their home and helps people stay out of hospital.

Preventing hypertension (high blood pressure)

Hypertension is a key risk factor for heart disease, which contributes to a quarter of all deaths and is especially prevalent in our most disadvantaged communities.

The ICB is working with Primary Care Networks (PCNs) to identify people who have undiagnosed hypertension.

Further work is taking place during 2024/25 to use data to really focus on addressing inequalities, especially in wards where low hypertension prevalence has been identified.

CHC improvements

Continuing healthcare (CHC) is when a package of care is required for a person over 18 with a primary health need.

Prior to the ICB, only one out of eight areas in Lancashire and South Cumbria provided an integrated operation in-house. It was the best performer and we therefore transferred more than 200 staff into the ICB to integrate the service.

We had a backlog of 4500 cases, and only 60 per cent of assessments were being done within 28 days.

Following the transfer, we are now consistently achieving the target of completing 80 per cent of assessments within 28 days. This means that the quality of the service, which supports some of the most vulnerable people in our area, has greatly improved and we are working in partnership with our local authorities.

The adult health and care team won the ‘high performing team of the year’ award at our internal ICB staff excellence awards in autumn 2023.

Improved ratings for two of our trusts

University Hospitals of Morecambe Bay NHS Foundation Trust has moved from a ‘system oversight framework’ (SOF) rating of four, up to three. This takes the Trust out of the ‘Recovery Support Programme’.

Lancashire and South Cumbria NHS Foundation Trust received a rating of ‘good’ from the CQC, and has moved from SOF 3 to SOF 2 by NHS England. The Trust was praised for its leadership, the quality of its crisis service and its management of the workforce.

Tackling health inequalities

One of our most targeted approaches to tackling health inequalities is our work with partners and with communities in some of our electoral wards with the highest levels of socio-economic deprivation and poorer health outcomes. These wards are known as ‘priority wards’.

One example, The Healthier Streets project in Barrow-in- Furness, has targeted four streets in one of the most deprived areas of the town. Working with community-led Love Barrow Families, the idea is to create a sense of belonging and ‘neighbourliness’ to combat loneliness and isolation, support mental health and reduce attendance at both A&E and GP practices.

New contracts for children and young people’s mental health services

We awarded 20 new contracts to four providers to deliver children and young people’s mental health and emotional wellbeing services a robust competitive tender process.

The services include counselling and therapeutic support, peer support and parenting support, ADHD and online support.

The principles set out in the new service specifications were developed with young people, parents and carers.

Single approach to workforce across Lancashire and South Cumbria to improve quality and value for money

We are setting up a shared bank and agency workforce service across Lancashire and South Cumbria to eliminate duplication and enable better sharing of skills and best practice in an environment that supports people to easily work in different trusts across our health system.

We have also agreed an approach for shared services for five functions within our trusts:

• Digital and information
• Estates and facilities
• Finance
• HR, and
• Procurement

We introduced a standardised maximum rate that the four main trusts will pay for agency nurses. In the 10 months to January 2024, we reduced agency costs by almost £5 million.

East Lancashire Hospitals Trust will be the single shared platform host and work is under way to establish one payroll system for Lancashire and South Cumbria.

Transfer of community and children and young people’s mental health services

We worked closely with East Lancashire Hospitals NHS Trust (ELHT) and Lancashire and South Cumbria NHS Foundation Trust (LSCft) to facilitate a transfer of community services between the two trusts. This saw adult community physical health services in Blackburn with Darwen transfer to ELHT and children and young people’s mental health services across all of East Lancashire moving to LSCft.

The aim of the transfer is to offer more seamless care with improved access, giving people a much better overall experience.

There is an intention to move to a single model and standardised approach for CAMHS, and this is the first step on that journey.

Trust cost improvement programmes

£241 million of savings were realised in the last financial year, 69 per cent of which were recurrent. This equates to 6.6 per cent of the total funding allocated to the NHS in Lancashire and South Cumbria. This is the highest cost saving ever recorded in this area.

Being ahead of the game on controlling spend

We took the decision at the establishment of the ICB to introduce strong grip and control measures, similar to the controls NHS England might introduce during intervention, to better manage our finances. We quickly put in place measures to reduce unnecessary spend across the NHS, in collaboration with provider trusts, across Lancashire and South Cumbria.

These measures put the ICB in a good position for when national measures were announced by NHS England. By introducing these early controls, and demonstrating a clear vision for reducing our deficit position, we have been able to work proactively with NHS England to reassure them of our robust delivery plans.
 

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Our financial situation is not where we would like it to be. We inherited a large deficit as the ICB was established, and as a leadership team we took the decision to introduce voluntary NHS ‘grip and control’ measures from the very beginning. We also had to make some difficult decisions at the time, such as committing to a zero per cent uplift on our non-statutory contracts, which was a shock to the system for a new ICB, but we are now starting to see the green shoots of recovery because of it.

Over the past year, a lot of effort has gone into closing down the deficit, but it remains bigger than we want it to be, which it is uncomfortable.

While our transformation plans - including quality improvement and cost saving plans - are not perfect, they are a lot more robust than last year, and we can continue to build on the two thirds of the recurrent savings that we made alongside our system partners.

We are moving in the right direction and although our position is still not positive, it is better than it was and it is therefore important to recognise what is behind that improvement, including much hard work from colleagues in the ICB and in our five trusts.

Local benchmarking data shows we are the second highest in the country for spend on acute care per weighted head of population, and while our system does perform well, we do not get the second highest outcomes in every area, plus we have a big deficit on top.

We remain open about the risks that we face and continue to keep our board members and NHS England colleagues informed so that there are no surprises, for example in relation to our final year-end position.

We have been able to agree a system control total deficit of £175m with NHS England, which is still a huge number and there will be a lot of work to make sure we achieve this by the end of the year.

For the ICB alone, we have agreed to end the year with no more than £95m deficit. Part of the reason that we have been able to agree such a high number is down to the confidence the national team has in our plan and how robust it is.

We should therefore have confidence in the fact that we are doing the right thing and we are making real progress in our underlying position. It is hard work and will require more hard decisions as we go along, but we need to keep the faith and focus on delivery.

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As an ICB, when we refer to ‘place’ we are talking about the four smaller geographical areas that Lancashire and South Cumbria has been divided into. These places align broadly to the main local authority areas and allow us to consider bespoke needs and priorities of people at a local level.

Delivering improvements in health and wellbeing and putting our population’s needs at the heart of everything we do requires us to organise and deliver care at the most appropriate level and closest to the residents we serve. Our four places are at the heart of this and are the key to ensuring our residents have healthy communities, high-quality services and a health and care service that works for them.

The four places are:

• Lancashire
  Split into three localities – east, north, and central.

• South Cumbria
  The South Cumbria boundary is not aligned with any one local authority which results in more complex partnership working across three councils.

• Blackburn with Darwen

• Blackpool

It is our ambition in Lancashire and South Cumbria to have a high-quality, all-age, community-centric, integrated care system which has our four places at its heart, acting as the engine room for driving the transformation and changes needed to improve health outcomes and experiences, responding to the needs of our population.

Our place aims are:

• A much stronger focus on prevention, transforming health and care services from being reactive to proactive, and designing new and improved prevention strategies.
• A step change in community-based services, with much greater integration of planning and provision between the NHS and local councils.
• Delivering high-quality care for priority diseases, conditions, population groups and communities.
• Getting better value from our collective resources – money, people, buildings and digital assets.
• Using data and intelligence to focus on local needs, making better use of what is available across different organisations to inform planning and delivery.
• Strengthening of places and neighbourhoods to ensure decision-making happens closer to and with local people, moving resources and changing the way organisations invest in, provide and manage services.

These aims will be delivered more effectively through the implementation of the place integration deal; where resources from the ICB and other partners over time are embedded further into our neighbourhoods and places. In the future, we expect delegated decision-making will support further aligning and/or pooling of resources with local authorities, ensuring a targeted approach to local need and making better use of our collective resources.

Delegation of budget to place

As part of the original place integration deal, our plan was to delegate budgets to place from April 2024. Under our current financial circumstances we took the decision to pause this delegation, though we remain committed to the development of place.

Delegation of budgets is a big administrative process that consumes a lot of time and energy and would not be the best use of our finance function in our current circumstances.

Our shared ambition across the system is for our places to have a big influence on what we do and our places being aligned to our recovery and transformation programme provides the most opportunities for our places to utilise the expertise and collaboration of a number of health and care organisations to tackle our biggest problems.

There may be specific areas that we delegate to, such as the Better Care Fund or discharge management, where it makes the most sense to do so.

Using place to support recovery and transformation

Our places have a vital role to play in contributing to the transformation and recovery of our system.

All four places will focus on admission avoidance, smooth and efficient discharge management and the vitally important goal of eliminating corridor care over two years.

Place teams will be able to focus on the delivery of services at a local level and support the transformation of community services. By getting this right, our work at place will help us to create healthy communities, establish integrated neighbourhood teams and enhance care at home.

Working at place can also support reducing hospital admissions and improving discharge. Local teams have begun identifying community-based initiatives in their areas to support admission avoidance and timely transition of care from hospital to community settings. This is in addition to creating capacity for intermediate care and creating a hub to support independence for the frail and/or elderly.

We want to ensure people receive early interventions and help managing long-term conditions and their overall health so they do not end up at A&E. We know conditions can worsen over time so population health is an important area of our work and will help support avoiding hospital admissions in the long term. This includes looking at the disproportionate number of people going to A&E from priority ward areas.

There are also big opportunities around discharge management, which is very fragmented between the local government, hospitals and community and primary care, with multiple interfaces. This is one of the areas that would really benefit from our places working collaboratively to help us to manage discharges more efficiently and effectively going forward.

Priority wards

Priority wards are some of the areas with the highest levels of socio-economic deprivation and poorer health outcomes.

These wards are where there is a higher number than expected of attendances and admissions into the urgent and emergency care department and where there are high levels of deprivation within the community.

This work has been developed working in each of the four place-based partnerships in Lancashire and South Cumbria. These partnerships include representatives of health, local authority, voluntary, community, faith and social enterprise (VCFSE) organisations, independent sector providers and the wider community, and work together to plan and deliver services. They also work together to make sure our services are joined up to improve health and wellbeing outcomes for the population, prevent people from being unwell and reduce health inequalities across our neighbourhoods.

Priority wards have been identified by looking at data and intelligence held by health and care partners, including health, local authority, VCFSE organisations, independent sector providers and the wider community, and there are 33 priority wards across Lancashire and South Cumbria.

Place success stories

Blackburn with Darwen: Family hubs

Four family hubs have been established at children’s centres in Darwen, Livesey, Little Harwood and Shadsworth. The family hubs offer support from conception through to age 19, or up to 25 for children with special education needs and disabilities. Parents can also access a range of support through the hubs from midwifery to mental health support, health visiting to infant feeding advice. In addition, the hubs provide early language and communication development for young children to set the foundations for lifelong learning and prepare them for school at age five.

Blackpool: Community engagement in priority wards

The ICB has worked alongside Healthwatch Blackpool and community group Revoelution to undertake community outreach activities in the five priority wards in Blackpool. These are Bloomfield, Claremont, Talbot, Tyldesley and Park. More than 700 doors were knocked on and more than 400 people shared their experiences with discussions taking place either in people’s homes or in community-based focus groups. Fourteen themes were identified from the experiences shared, from access to health and care and the cost of living crisis to the challenges of social isolation.

Lancashire: Working differently to support disengaged patients

Having acknowledged that some people who have experienced trauma can become disengaged from the NHS, the Lancashire team has worked with GP practices in the Morecambe Bay and Lancaster area to support people in a different way. The team carried out enhanced health checks via a stealth community development outreach approach of building trust, empowerment, collaboration and fairness with disadvantaged communities. This has resulted in the majority of people who live in the targeted communities who have had no previous contact with the health service for many years being reached, having a health check and, in some cases, receiving treatment for serious health issues.

South Cumbria: Engagement with people living in Barrow

Being among the most deprived areas in Lancashire and South Cumbria, Poverty Truth Commissions were established in Barrow. This included people with a lived experience of the struggle against poverty as well as leaders within the town and wider Furness region, such as representatives from the NHS and the council, as well as from large-scale employers in the town. A key concern has been the health and wellbeing of the population and the need to provide a different model of support for those who are unable to work due to mental or physical ill health.

More targeted engagement is happening through the Healthier Streets project in Barrow. The aim is to build an increased sense of belonging and neighbourliness in four streets within priority wards in the town as well as addressing a number of long-term, complex challenges that residents are facing. The project has been built from the bottom up and developed with residents, 10 of whom have become ‘community champions’. This approach is providing a benefit to some of the most vulnerable people in Barrow and will become a blueprint for our work with other communities in the town and further afield.

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In the last year we have taken a big step forward with the Lancashire and South Cumbria New Hospitals Programme. We now have funding envelopes to build two new hospitals to replace Royal Preston Hospital and Royal Lancaster Infirmary.

By the time we build the two new hospitals, our delivery model needs to have completely transformed to fit the growing needs of the population so the demand for services does not overwhelm the system. If we do not change our delivery model, in the next 10 years or so, we would have an unaffordable challenge.

We currently deliver a £4.5billion budget through a hospital-centric delivery platform, with 60 per cent of our money spent on hospitals.

If nothing changed, we would need to increase our hospital budget by 60 per cent by 2038 to deliver the same level of healthcare that we currently provide, which is not affordable to any government, no matter how much they value health services and the NHS.

If we look at how healthcare services may be accessed in the future, we can see some of the key drivers of change mean we need to move much more of what we deliver into the community.

Over the coming years, the way people access health services will look different. We know the number of people aged over 85 with multiple long-term conditions is likely to double within 25 years, plus we have a generally ageing population with greater health need, increased demand and longer waits for treatment as a result of long covid, population growth, poverty and the cost-of-living crisis.

According to data from The Health Foundation, the three standout health issues expected to increase in prevalence are chronic pain, diabetes and anxiety and depression, all of which should be provided in the most appropriate care setting, which in some cases may be through primary and community settings rather than hospitals.

The significance of this is reflected in the projections for hospital bed days in the future, if our approach to delivering services remained the same:

• For over 65s the increase in total bed days is 21 per cent by 2023, and 63 per cent by 2043;
• For over 85s the increase in total bed days is 3 per cent by 2033, and 63 per cent by 2043.

This is clearly not affordable.

With such data available to us now, it would be foolish not to use this information to inform the way we radically transform health and care in Lancashire and South Cumbria to shift the balance from hospital-centric to community-centric.

We need to plan the right size hospital, the right clinical model and the right community and primary care model. And they all have to happen simultaneously.

If we do not change our delivery model, we will not be able to provide the care that will be needed by our population in 2035. The Jean Bishop Integrated Care Centre in Hull is an example of the kind of integration we quickly need to explore and find ways to implement in Lancashire and South Cumbria at pace and at scale.

Plans to replicate this model are underway in South Cumbria, with several workshops already having taken place. The pilot, which is proposed to launch later this year in Barrow-in-Furness, will be tailored to the needs of the population with the overarching aim of promoting independence for those who are frail and/or elderly.

We have to make some hard choices and it can’t all be done by efficiency. We are a reasonable performer for a lot of the national metrics in Lancashire and South Cumbria, above average in many cases, and we know there are lots of opportunities to do things better, faster, smarter, but it goes beyond that. Given the scale of the problems we face, it is not possible to focus on everything. It is only possible to make a tangible difference in outcomes by focusing on fewer areas.

We therefore must focus on moving towards community transformation and prevention by doing more of the positive things already covered in this report.

It will mean difficult choices, but if we don’t make these choices, we may not lay the necessary foundations for the new hospitals as part of our wider new clinical model.

The Jean Bishop Integrated Care Centre

The Jean Bishop Integrated Care Centre in Hull is a great model of admission avoidance, providing a central hub for NHS, social care, voluntary, fire and rescue services to work collaboratively to keep thousands of frail and elderly people fit, out of hospital and living independently at home or in their care setting.

Following an initial assessment in their own home or care setting, each patient is seen at the Jean Bishop centre by a clinician (either a GP with an extended role in frailty, a consultant community geriatrician or an advanced nurse practitioner), a physiotherapist, social worker, voluntary services worker and other specialists. There are also diagnostics facilities, which enable healthcare staff to carry out blood tests, x-rays and in the near future CT scans as required.

At the end of their visit, each patient receives their care plan, knowing they have been listened to by healthcare professionals who have the time to listen and identify what is important to each patient, and reassured their plan will be implemented and monitored.

Between April 2019 and September 2022, the Jean Bishop Integrated Care Centre contributed to a 13.6 per cent reduction in emergency hospital attendances for patients aged over 80. Over the same period there was a 17.6 per cent reduction in emergency department attendances for patients in care homes. Following its success, the service has now been rolled out to cover the East Riding of Yorkshire.

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Improving quality

The whole point of transforming and reconfiguring services is to improve the quality of services and, ultimately, outcomes for our patients.

We are currently developing a clinical configuration blueprint and a roadmap for its delivery. This will help us make sure we meet the needs of people living across Lancashire and South Cumbria in the future with services configured in a way that is proven and appropriate to make the best use of all the resources we have at our disposal.

We need to stabilise services and make them less fragile while reducing duplication. This will involve consolidating out-of-hours rotas, sourcing specialist equipment and teams and reducing the bureaucracy and management overheads associated with multiple services that are doing the same thing.

And by adopting the recommendations of Getting It Right First Time (GIRFT) and adopting policies and procedures from the top performing hospitals to increase productivity we will start to standardise clinical diagnosis and treatment. It is important we reduce the amount of unnecessary variation during services experienced in different areas of the region.

Our work in this area will involve looking at the workforce, in particular ensuring that we have strengthened and consistent services across our hospitals with a robust approach to providing mutual aid, along with a structured approach to the use of bank and agency staff and new roles that reduces unnecessarily expensive staffing costs and variations across trusts in their use of roles and bandings.

"It is important we reduce the amount of unnecessary variation during services experienced in different areas of the region.”

Transforming care in the community

We want to transform community services in order to reduce inequity, improve how long people can expect to live a healthy life and to avoid admissions to hospital.

We will do this by focusing on three areas:

1. Creating healthy communities

People thrive when they are connected, so we want to bring people together with their neighbours as well as with local groups, activities and events. We will work at focused place levels to provide forums for ideas to emerge from the community encouraging residents to take control of their health and wellbeing.

2. Integrated neighbourhood teams

Bringing together teams and professionals to improve care for people within their communities. These will include staff from primary, community, secondary and social care, domiciliary and care staff, population health and VCFSE partners. These teams will be able to share information and resources to improve health and wellbeing and tackle health inequalities.

3. Enhanced care in the community

Supporting people to recover and increase their independence through enhanced support based on their needs to enable them to remain at home or as close to home as possible. This will bring together care teams to support people with physical care needs, crisis services, home-based and bed-based support.

Transforming care in our hospitals

We plan to completely overhaul the way hospital services are configured, with one high-quality teaching hospital providing all the most specialist and complex services, such as neurology, with district hospitals providing the standard services at a local level.

All these services would work together to transform clinical services and improve outcomes, safety and efficiency through establishing centres of excellence and surgical hubs which provide a high quality of care.

This reconfiguration aims to make the best use of some of our specialist staff working as part of clinical networks to provide consistent and high-quality care and provide access to regular tests and monitoring for these much closer to home, such as rehabilitation in community settings for stroke patients, or in the home through technology.

Our plan includes a rolling programme to transform some of our most fragile services, such as haematology, orthodontics and gastroenterology so they are provided by teams working collaboratively as a network at designated centres of excellence.

We will also look to centralise some specialist surgical services sooner, such as vascular, urology (bladder, kidney and prostate cancers), head and neck cancer and cardiac, where evidence has shown that centralising services leads to better outcomes for patients and a more sustainable staffing model.

We need to significantly improve the quality of our buildings. This includes our hospitals and mental health facilities. The New Hospitals Programme is a long-term project that will see two new hospitals built to replace the current ageing Royal Lancaster Infirmary and Royal Preston Hospital buildings. Work is also planned to develop a new mental health facility on the former Calderstones site in Whalley, while we also want to improve the quality of life for those with learning difficulties by moving people out of hospitals. Plans also include major improvements, refurbishments, and new-build phases across other hospital and mental health sites. Being able to locate clinical services next to each other in the most productive way would be a big benefit. Our infrastructure will be transformational, enabling new integrated models for both clinical pathways and prevention, while improving long-term health outcomes.

We will prioritise the development of our urgent and emergency care strategy including the role of future district general hospitals model, urgent treatment centres and other system assets. If left unchecked, demand for unplanned urgent and emergency care will continue to escalate and this represents the biggest risk to our sustainability.

Transformation of planned care will include the expansion of surgical hubs, working with the independent sector to expand the specialities and type of cases they undertake to align to waiting list priorities, improving referrals, waiting list management, and theatre and outpatient transformation.

The role of the Integrated Care Partnership in steering transformation

There are far greater opportunities available in how we achieve our aims of tackling health inequalities, improving outcomes in population health and supporting broader social and economic development when we work as equal partners within a health and care system.

Lancashire and South Cumbria Integrated Care Partnership (ICP) was created at the same time as the ICB, and aims to support people in Lancashire and South Cumbria to live longer, healthier, happier lives than they currently do. Recognising the wider issues that affect health and people’s overall wellbeing is a big part of how we will support people to remain healthy and well.

The partnership will play a key role in steering our progress within transformation, including enhanced care at home, healthier communities and integrated neighbourhood working. This is because the ICP can help to tackle the most complicated issues affecting people’s health and wellbeing that can only be solved by different organisations working together with communities.

In 2023, the Integrated Care Strategy was published, setting out a clear vision and set of priorities which all organisations in the partnership contribute to.

At a workshop in June 2024, the core partner members of the ICP discussed how we move beyond establishing a committee to putting in place a different format of partnership which gets the best setup for Lancashire and South Cumbria. There was a clear consensus for having a small number of projects that the partnership really focuses on delivering together.

Over time, the ICP will become the focal point for joined-up working between partners at system level, effecting long-term transformation and driving improvements in health and wellbeing outcomes for our communities.

“The ICP can help to tackle the most complicated issues affecting people’s health and wellbeing that can only be solved by different organisations working together with communities.”

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We have got a good plan, but it is high-risk and requires all parts of the system to work closely together to carry out major reconfiguration and manage a smooth transition of services into the community. The scale of change is vast and it is not surprising the execution of such an ambitious plan is challenging. 

As we prepare to move forwards into the real transformational phase, we need to be prepared for the fact it will get messy. Decisions will be taken on the best information and advice available at the time, but with hindsight, perhaps in the next iteration of this report, may be seen as mistakes. 

The leaders of our health and care system are going to face some extremely challenging circumstances as we embark on the almost impossible journey of transforming an entire health and care system while managing the day-to-day challenges of system performance, growing demand, winter, industrial action, workforce challenges and financial pressures.

One of the most important elements of any major transformational change is making sure there is clear leadership and a positive culture for change at every level of the system. Our people are our greatest asset and it is important to ensure our leaders have the right tools and support to be able to deliver these programmes. In getting this right our leaders will be empowered to make the big and difficult decisions that need to happen for the overall benefit of the people of Lancashire and South Cumbria. 

In this health system we have never delivered change on the scale that is required for us now, to prepare for the two new hospitals we aim to build. In some of our biggest programmes of transformation it will require a step change, not just in the ICB but throughout the whole health and care system and the way we work together. It also includes how we integrate health and care and work in partnership with local authorities, voluntary, community, faith and social enterprise partners, education, businesses and others.

Alongside the work we are undertaking to integrating care at a local level, including the pilot in Barrow-in-Furness, we are also looking at ways in which virtual care could be utilised better across health and local authority to carefully target patients at risk of going into hospital, or those currently in hospital with moderate health needs that could be managed at home.

Another area we are keen to explore is how we can use NHS and local authority resources better between us. The Better Care Fund (BCF) programme was set up to support local systems to deliver the integration of health and social care and established pooled budgets between the NHS and local authorities, aiming to reduce the barriers often created by separate funding streams. The obvious next step was to look at how we utilise the BCF more efficiently to target the right priorities and reduce health and local authority spend. If we can better use the BCF, it could enable people to be discharged from hospital when they no longer need to be there. In turn, this would reduce the pressure on the system and improve the flow of our health and care services.

This is not just about our organisation. We have a good plan that is high risk, but the only way we can achieve it is by working together in perfect harmony with all of the organisations in Lancashire and South Cumbria being at the top of their game. 

We need to work closely with some of the key partnership forums to get the best possible outcomes for our communities, including the health and wellbeing boards that hold the statutory duty to agree and approve the BCF. 

It is not a simple exercise, and with our ICB covering no less than six local authority areas, we have yet to reach an agreement that works across our whole region. Through a comprehensive system-wide review of the BCF across the four places, we are seeking an approach to maximise joint funding across the ICB and local authorities. There is no overnight solution, and it will take time to get this right. However, this is the single most important aspect of the relationship between the NHS and the local authorities because, without this, there is no true integration.

I have worked for five English local authorities across the country, and I have been through austerity in local government; I know how challenging it is. 

We are very fortunate in our area to be able to work with six steady, high-performing local authorities, and we are continuing to develop relationships that can help us to better integrate health and social care to ensure improved outcomes for our patients.   

Local authorities play a huge role in terms of social care and child protection. In relation to transforming care, there is a small number of high need and complex patients that require extremely specialised and time-intensive care, and these patients are a priority for all partners involved.

There are, however, some inequities in how these complex patients are funded by different councils and it is vital that we work with our colleagues in the local authorities, recognising their own challenging financial circumstances, to address the imbalance and ensure there is consistency in shared funding arrangements across the system. 

This is a fundamental test of our partnership working and is one of the key things for us to get right over the next year. If we cannot tackle some of these difficult issues together, then it is not possible to progress with our shared agenda.

We find ourselves in a challenging position, but ever the optimist I see the potential and the opportunities that could get us to where we need to be, or at least driving in the right direction.

That is not to say that it will be easy, but there are some fundamental components of success we need to be striving to achieve, which are the golden threads running throughout this report.

Firstly, as a commissioning organisation, we will need to improve our efficiency by moving from micro-commissioning to more strategic commissioning and making sure the investment we make is matched by the level of performance. If there are areas we are investing at a premium rate, we would expect to see premium performance as a result of it. We have innovative and dedicated people working within our organisation and they should feel they have permission to explore opportunities, get out of the status quo and use their skills and experience to solve our biggest problems.

This extends to our leaders, and it is clear we have a great need for strong leadership. There are going to be some difficult decisions to make as we navigate the next few years. Undertaking transformation on this scale is not for the faint-hearted. However there needs to be a strong support system and our leaders across health and care should not feel they are embarking on a solo journey.

Our relationship with the local authorities needs to continue to evolve, with more focus on joint teams working across NHS and local government and better utilisation of the Better Care Fund, working through our place-based partnerships to review the base budget and priorities in each place to see how we can reprioritise the funding. If we are to be a truly integrated health and care system, cost-sharing with local authorities would become the norm, and the resources we have available for the people of Lancashire and South Cumbria would be better utilised.

We need to recognise this is not an overnight fix, we face a complex and challenging picture and we therefore need to remain patient. True transformation takes time and requires trying things that may be out of our comfort zone, with the very real possibility of failure. I am sure the learning we will undertake as part of this journey will be vast, but I am a firm believer in facing problems head on. We should be patient, but firm in our expectations of progress.

Our workforce – and that of our wider partners – and the people living in our communities across Lancashire and South Cumbria are critical for the success of our vision for the future. With the calibre of our people and the commitment and enthusiasm I see every day from our citizens, I am confident we will get there together.

We have to keep the car turning away from the cliff edge, and on to a road to a brighter future for everyone in Lancashire and South Cumbria.

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