Empowering local leaders

"Please share examples from the health and care system, where local leaders and organisations have created transformational change to improve people’s lives. This can include the way services have been provided or how organisations work with residents and can be from neighbourhood, place or system level."

West Yorkshire Association of Acute Trusts (WYAAT) is an acute provider collaborative of six acute trusts working together to provide high quality, sustainable services to the population of West Yorkshire and Harrogate.

One of the first complex programmes of work led by West Yorkshire Association of Acute Trusts (at the request of the Strategic Transformation Project at the time) was to review its vascular provision based on a recommendation from the Yorkshire and Humber Clinical Senate. The trusts collaboratively reviewed the number and location of its arterial centres and made a recommendation to the system and NHS England which was then subject to an in-depth and full public consultation. The recommended option was then implemented by West Yorkshire Association of Acute Trusts, engaging with patients and clinicians to improve pathways and introduce new pathways and models of care including ensuring that a patient has rapid access to a senior opinion to avoid delays in their treatment and reduce the number of hospital admissions. The creation of the urgent vascular assessment clinic, virtual ward, and repatriation pathways ensures that patients can be treated as close to home as possible and can reduce the amount of time the patient needs to spend in hospital.

This way of working has shown the importance of provider collaboration and how this can deliver real change for patients, supported by the wider system.

"Do you have examples where policy frameworks, policies and support mechanisms have enabled local leaders and, in particular, ICSs to achieve their goals? This can include local, regional or national examples."

West Yorkshire Association of Acute Trusts predates Strategic Transformation Projects (STPs) and later Integrated care Systems (ICSs) in its collaboration and is a successful and early example of a horizontal provider collaborative. The permissiveness of the policy guidance to date has enabled West Yorkshire Association of Acute Trusts to thrive and deliver real transformation as part of the wider ICS including recommending and implementing the vascular reconfiguration across West Yorkshire which reduced the number of arterial centres, improved patient pathways and has resulted in a reduced length of stay for patients.

Our success has negated the need for costly, complex, and disruptive mergers or group models but has allowed us to achieve benefits for clinical and operational teams and patients.

West Yorkshire is successful in its balance of subsidiarity – both with its provider collaboratives and its constituent places and has worked within the policy frameworks to achieve this. We are able to get things done as we work at the right level to achieve the most benefit, neither the central Integrated CareBoard nor the Integrated Care System attempts to hold all the responsibility or accountability in the system. It is devolved through distributed leadership to the most appropriate organisations or partnerships within it.

"What do you think would be needed for ICSs and the organisations and partnerships within them to increase innovation and go further and faster in pursuing their goals?"

• Greater autonomy from national and regional directives to focus on local priorities. Nationally, there needs to be a focus on medium-term objectives (long-term is well described in the Long Term Plan) but greater autonomy is needed in respect of how these are achieved in a way most suitable for the system and its population.  
• Clear outcomes set with the autonomy for systems to agree its own additional local priorities and the appropriate delivery mechanisms and measures of success would enable greater pursuit of innovation.  
• There needs to be the removal of perverse incentives through volume measures which can force a dichotomy between securing income for services and the right pathways for patients.
• Improving the quality and quantity of data available to systems to support improvement and innovation, alongside this there needs to be greater clarity and clear framework for information governance to enable us to share data and better plan services.
• Access to capital funding locally rather than nationally ringfenced pots would also allow greater innovation linked to local priorities.
• A longer-term technological view from the centre e.g., the future impact of AI.

"What policy frameworks, regulations or support mechanisms do you think could best support the active involvement of partners in integrated care systems? Examples of partners include adult social care providers, children’s social care services and VCSE organisations. This can include local, regional or national solutions."

Policy frameworks need to consider how partners from local authorities, Voluntary, Community and Social Enterprise (VCSE) sector and wider public services can become equal partners in pursuit of improving the health and wellbeing of whole populations at an Integrated Care System level. Investment is also key and at a national level there needs to be a settlement for social care in line with NHS in exchange for parity in accountability for delivery.

National targets and accountability

"What recommendations would you give national bodies setting national targets or priorities in identifying which issues to include and which to leave to local or system-level decision making?"

National targets and priorities should be centred around the delivery of overarching outcomes with an agreed set of indicators directly measuring outcomes, or a proxy set of process or output measures where this is more challenging, or where the change in outcomes is perceived to be a long-term endeavour.

By focusing on outcomes, and fundamentally the triple aim, this should avoid driving behaviours which may not benefit patients or incentivise the wrong pathways for patients e.g., focus on volumes of appointments rather than pathways which have the most benefit for patients, but result in the overall volume reporting appearing lower.

National bodies should focus on the big issues in line with the Long Term Plan to ensure there is not unwarranted variation for patients between systems. Systems and providers should then be free to determine how these priorities are implemented, monitored, and measured, again avoiding the pitfalls of focusing on input and process measures outside of an operational delivery level.  These should be designed and agreed by all partners at a system level.

Similarly, a greater number of priorities which specifically require joint working across sectors will clash with sector-based performance and quality measures, as well as investment.

"What mechanisms outside of national targets could be used to support performance improvement?"

Examples could include peer support, peer review, shared learning and the publication of data at a local level. Please provide any examples of existing successful or unsuccessful mechanisms

Availability of data at a local level to inform local and national comparison and benchmarking, as well as aiding a more sophisticated data science approach to modelling demand and understanding inequalities to support service planning. This requires the ability to join-up data sets across services and across systems which requires systems to be supported with the data science and public health capabilities to undertake this work. Alongside this is the need for clear and embedded approaches to community and patient engagement to enable improvement in access, experience, and outcomes.

Peer support and shared learning is fundamental to performance improvement. This is the basis of much of the work we do within West Yorkshire Association of Acute Trusts and as part of the broader West Yorkshire Integrated Care System. A strong set of relationships and a culture of transparency has provided the basis from which we are able to share quality, performance, and finance information to identify unwarranted variation and best practice and therefore to make improvements.

There is an opportunity to consider how the CQC framework can support a culture of improvement rather than purely focus on regulation and legislation.

Data and transparency

"Do you have any examples at a neighbourhood, place or system level, of innovative uses of data or digital service?"

Please refer to examples that improve outcomes for populations and the quality, safety, transparency or experience of services for people; or that increase the productivity and efficiency of services

West Yorkshire Association of Acute Trusts operates at a system level as a collaboration between six acute provider trusts. We have implemented several transformation programmes across that footprint. We are currently implementing several single systems:

• Pathology LIMS – enables us to work as a single network and deliver the standardisation and consolidation opportunities outlined in the Carter Reviews of 2008 and 2016
• An image sharing solution enabling images to be reported from any trust in West Yorkshire Association of Acute Trusts (and into neighbouring Integrated Care Systems) supporting clinicians to do ‘insourcing’ work and reducing outsourcing costs to the system.
• Inventory management system supported by a single catalogue – reducing product waste across the system, enabling products to be moved between trusts when nearing expiration.
• West Yorkshire Association of Acute Trusts was among the first group of acute trusts in the country to analyse our waiting lists through an ethnicity and IMD lens to support targeted interventions to reduce inequalities in waiting times for planned care, including for example prioritising patients with a learning disability.
• Sharing detailed waiting list information to enable providers to identify capacity and offer opportunity for patients to be seen quicker at alternative sites to their local hospital.

"How could the collection of data from ICSs, including ICBs and partner organisations, such as trusts, be streamlined and what collections and standards should be set nationally?"

As previously stated, if the national standards are focused around outcomes, this should reduce the number of measures (outcome measures or output or process measures as proxies) that are required to be reported nationally. Reporting and assurance against these outcomes should be directly linked to national priorities set through the Long Term Plan and the operational planning guidance for the current financial year. Where possible, reporting measures required against additional funding (capital or revenue) to support specific schemes, should also be linked to these outcome measures.

Currently, there is a huge amount of reporting and assurance required from providers to a system, regional and national level. Often this is very detailed and focused on input or process measures which can have little utility outside of an operational setting. Where this information is being used to support benchmarking, this should be combined into fewer submissions e.g., into Model Hospital submissions rather than as additional requests from individual programme teams in NHS England.

As a result of a more streamlined process, this would release significant additional capacity in analytics, performance, operational and senior management time which can be redirected to service delivery, more complex and valuable modelling, and service improvement activities.

"What standards and support should be provided by national bodies to support effective data use and digital services?"

• Fewer national / regional returns with clear links to outcomes – clear data definitions to ensure comparability and support for providers / systems to provide this information where required.
• Ability to then undertake accurate benchmarking on a ‘like for like’ basis at a system, regional and national level.
• Shared access to a wealth of data from across sectors within the system to support with sophisticated data science approach to modelling, forecasting and analytics which will inform service planning in the short, medium, and long-term.
• Digital investments need to ensure support and resource available to secure the basic infrastructure within organisations and systems. Greater requirements for digitisation and sharing of systems and data cannot continue to be layered upon old infrastructure.
• Clear policy direction in respect technology developments and use of e.g., AI and assistive AI.

System oversight

"What do you think are the most important things for NHS England, the CQC and DHSC to monitor, to allow them to identify performance or capability issues and variation within an ICS that require support?"

Quality and safety, patient experience and outcomes are the most important aspects of NHS services that national bodies should monitor.

CQC should continue to be focused on assessing the quality and safety of services in line with the KLOEs, within organisations and across systems. There is an opportunity to use this assessment framework to be one which supports a culture of improvement and learning within organisations and across systems as well as providing the regulatory and legislative assurance in respect of service provision.

NHSE / DHSC should be focused on monitoring outcomes against key national priorities in LTP. The 23/24 Operational Planning Guidance is much improved in setting fewer priorities, some of which are still very detailed asks rather than high-level outcomes.

Systems should be devolved the responsibility to deal with local issues related to the triple aim and inequalities with assurances sought by national bodies that progress is being made from baseline position in each system, and that an appropriate infrastructure is in place to deliver improvements.

Sometimes nationally produced data sets can be distant from understanding service delivery, appreciation of local context and warranted variation. Sometimes variation is warranted (because of e.g., population demographics, local economic environment) and helpful, allowing for alternative approaches to be tested. However, this cannot be balanced against a single national performance measure. 

"What type of support, regulation or intervention do you think would be most appropriate for ICSs or other organisations that are experiencing performance or capability issues?"

Support is likely to be unique to each system or organisation dependent on the nature of the issue or challenges faced by that system. Equally, context is extremely important, performance must be considered in the relative constraints of the system and what leaders can realistically achieve in the short, medium, and long-term in the context in which they and their organisation is operating. A performance improvement plan must be in place, but the pace and trajectory must be understood within the local context rather than set externally.  

Support should be offered and requested rather than enforced in situations which are not related to safety or leadership / culture concerns. This could be connecting with other systems, leaders, and expertise to seek learning and support from outside the system, or through a peer review process which organisations and systems often find valuable.

Intervention should be limited to those systems or organisations where there is evidence of safety concerns or damaging cultures which are impacting patients and staff.

There needs to be careful consideration about which body is supporting and intervening e.g., role of Integrated Care System vs NHSE in performance and SOF tiering arrangements and impact this may have on broader relationships / culture within a system.

In the West Yorkshire Association of Acute Trusts, we are very clear that the collaborative is about peer support and improvement, not performance management. Mutual accountability does not equate to performance management. Changing this dynamic would have a (likely negative) impact on the support and transformation we deliver as a collective.

Additional evidence

"Is there any additional evidence you would like the review to consider?"

Three key areas of scope are: empowering local leaders to focus on outcomes and retain/improve accountability, reduce the number of national targets, enhance the role of the CQC in system oversight.

West Yorkshire Health and Care Partnership's response to the Hewitt Review