Summary
Dr Tracey Vell MBE, Chair of Greater Manchester Primary Care Provider Board (GMPCB), shares her thoughts on neighbourhood working and how we develop as a system to ensure meaningful collaboration with all parties working on an equal footing.
For many years we thought that integration was the solution to system issues, such as flow to accident and emergency (A&E), hospital waiting times for diagnostics and interventions, outpatient costs, GP and dental access, social care costs and quality. And now we are considering the poor relation of the NHS – prevention and pro-active care.
Is more integration a solution or a by-product?
It seems that focusing on form leads us down expensive routes and as a result collaboration has become a popular phrase – no-one moves, but everyone shares focus.
In order to do this there are a few issues that immediately come to mind, the first of which is culture and hierarchy.
We need to work harder on breaking barriers within the NHS so that neighbourhoods do not become the emperor’s new clothes.
I don’t think system organisational development has ever truly been done at scale, but on behalf of our patients it should be prioritised.
Patients assume we all get on behind the scenes. The reality is that there are loud voices and there are quiet ones, and we don’t treat them all with the same courtesy or respect.
By only fully resourcing leadership in typical spaces, for example commissioning, we miss the opportunities to flatten hierarchy and truly solve issues.
I have been in several boardrooms where we have had to fight for a seat for primary care providers, as we are often only spoken to via a commissioner, or commissioning employed clinical lead.
Once on a seat, we are often marginalised and sometimes overwhelmed by language and overt power dynamics. If we feel like this, then imagine what a lay person or smaller voluntary sector organisation may feel like?
This allows for less than ideal participation and a pivot towards tried and trusted partners, who are often the wrong answer and have demonstrated deficits.
We have a responsibility to reverse this and consider a more compassionate leadership style where those with the most power speak less, do less and control less. For this to happen it needs expert system development and trusted mature relationships.
This is fundamentally not only the foundation of collaborative working, but secures the rest of the build on a firm footing.
What are some of the signs that this is happening?
- Chairs of system meetings are mixed and from diverse settings
- Resource is given to different and varied organisations to lead
- Contracts are distributed with clear accountabilities with a one resource model and not to single entities with sub-contract rights
- Outcomes become identified which require true collaborative working under true joint contracting
Only when the smallest and weakest voice is comfortable and happy, do we consider we have succeeded. We can then move on to other barriers to collaborative working such as:
- Meaningful contracts not short-termism – the longest terms should be in the least resilient organisations to support them
- Sharing resource across organisational boundaries – estates is a barometer of how well we do this and how many real and presumed barriers we put in the way
- Lack of digital strategy, connectivity and investment
- Procurement risks and issues – this is a whole piece on what NHS reforms in the past has done to systems and the lack of sustainability of those partners within the NHS body
The right environment and system development is key and we must deal with this first before we tackle the problems and find solutions.
If we have the right conversations with an absence of hierarchy, we are ready to discuss solutions together.
It is then truly possible to collectively define the burning platforms and duplications that are impacting the population’s health service.
We can also look at the enablers and share resource, rather than control it organisationally. For example estates and digital being fully integrated, allowing mobility and shared spaces.
Plus, re-thinking access from an organisational lens to all access being a system issue.
GP access cannot be solved by GPs alone, just as A&E waiting times are not simply a hospital issue.
I conclude with a faint glimmer of hope. I do not see neighbourhoods as the “messiah,” but see dedicated system development as the key that unlocks the door to solutions of which neighbourhoods may be one.
