11 January 2023
This paper can be downloaded as a pdf file here.
IN A NUTSHELL
In August 2022 the firm PricewaterhouseCoopers (PwC) was commissioned by the newly created NHS Integrated Care Board (ICB) for Cornwall and the Isles of Scilly (CIoS) ‘to review the current governance arrangements’ of the ICB. The PwC team failed to notice that the ICB had dropped from its former list of priorities two crucial ones: reducing ambulance delays and reducing health inequality. Nor did they ask whether the organizational structure of the Integrated Care System (ICS) was fit for purpose, i.e. appropriate for the world of health and social care: instead they preferred to apply their own ‘governance framework’ and focused only on ‘consistency’ and ‘clarity’.
The PwC ‘governance framework’ may be suited to pyramid-shaped corporations but has little relevance to ICSs, which are tasked with bringing about integration between NHS bodies, such as hospital trusts, and local authorities and voluntary bodies over which the NHS has no direct control. ICSs are intended to foster ‘joined-up thinking’ and working together, and an ICB has no formal hire-and fire power over their constituent parts. It would be more appropriate to think of the CIoS ICB as heading a health and social care ‘foster family’ – with teenagers!
So an entirely new way of thinking about and harnessing the resources of the constituent bodies of the new systems is called for. The authors of the PwC report have missed the opportunity to provide it. The opportunity still exists: this paper suggests steps towards seizing it.
Q1: Who are PwC, what is the PwC report on the governance of Cornwall’s ‘new integrated care system’, why is it important, and where can I find it?
A: PwC stands for PricewaterhouseCoopers, a company which describes itself as ‘among the leading professional services networks in the world’. It has offices in 152 countries and employs almost 328,000 people. It aims to ‘help organisations and individuals create the value they are looking for, by delivering quality in Assurance, Tax and Advisory services’.[1] The firm was formed by the amalgamation of two long-established businesses, Price Waterhouse and Coopers & Lybrand, who used to describe themselves as accountancy firms.[2]
In August 2022 Cornwall’s Integrated Care Board (ICB) commissioned PwC to carry out a study ‘to ensure the governance arrangements for the ICB are sound in both the stated structure and our ways of working’.[3] The report that PwC submitted, in November 2022, is called NHS Cornwall and Isles of Scilly: Corporate governance review and improvement programme. It was published as an insert in a document entitled PWC improvement programme[4] that was placed on the agenda for the meeting of the ICB held on 8 December 2022. It can also be viewed as a freestanding document.[5]
Q2: How did the PwC team work? What did they actually do?
A: The PwC team did not go back to first principles and ask ‘Is the ICB’s organizational structure fit for purpose?’, which would have called for a close study of the purposes for which ICSs have been created. What they did was to read internal documents and interview ICB members and officers, asking questions drawn from an invention of their own, ‘the PwC governance framework’.
That ‘governance framework’ is centred on five ‘key themes’: ‘Leadership, behaviours and culture / Structure and effectiveness / Risk identification and ownership / Management information and controls / Strategy and reporting transparency.’
The PwC team examined the documents and the answers that they received. We can see from their report that what they were looking for was inconsistencies and lack of clarity in those documents and answers. For example, under Leadership, behaviours and culture they note: ‘There was not a consistent understanding demonstrated of the vision, values, and strategic priorities of the ICB and wider system amongst the people we interviewed.’ Under Structure and effectiveness they write: ‘Some roles (e.g. Managing Directors) have job descriptions in place and but (sic) this is inconsistent with the role they are expected to do.’ Under Risk identification and ownership we find: ‘The inconsistent understanding and articulation of the ICB’s strategic priorities, and those of the system, inevitably result in a more immature risk environment than is desirable. Under Management information and controls they write: ‘Improvements are needed to provide a better system-wide view of performance, quality and financial metrics. Steps need to be taken to align reporting across the system, working towards one version of the truth …’ And under Strategy and reporting transparency they say: ‘Once agreed and consistently understood, the strategic priorities need to be socialised and agreed more widely to help instil clarity and facilitate the alignment of activity with the key areas of focus for the ICB.
As we outsiders can see, once we penetrate the management-consultant-speak, this is an all-purpose ‘conceptual framework’, basically a way of classifying. It is designed to be applicable to any kind of organization. It has no particular relevance to health and social care.
This is a serious omission because integrated care systems are a very different kind of organization from the familiar hierarchical pyramid characteristic of the modern corporation. An ICS in England encompasses not only NHS bodies, such as hospital trusts that run hospitals and outpatient clinics, accountable to NHS England, but also local authorities, charities and voluntary bodies which provide social care services of various kinds, over which NHS England has no direct control. So integration is all about fostering ‘joined-up thinking’ and working together among these disparate organizations, and an ICB has no formal hire-and-fire power over the constituent parts of the system. It would be more appropriate to think of the CIoS ICB as heading a health and social care ‘foster family’ – with teenagers! Not as a board of directors.
It follows that an entirely new way of thinking about and harnessing the combined resources of the new system is called for. The PwC team failed to grasp this point. The phrase ‘joined-up’ does not even appear in their report. And none of their five key themes even mentions the thinking behind integration. So they didn’t get round to asking the crucial question: Is the so-called CIoS integrated care system fit for purpose? Indeed, their report makes no mention of how health care and social care are interconnected.
Q3: What does the PwC report say about the ICS’s health and social care priorities?
A. The nearest that the PwC report comes to the nitty-gritty of health and social care is to point out that ‘The ICB has agreed 5 top priorities for 2022/23, covering: ‘Flow / Intermediate care / Elective recovery / Mental health learning disability & autism / Dementia.’[5]p.16/20
We aren’t told how these ‘5 top priorities’ came to be agreed by the ICB, but if we dig a little into the ICS’s recent history we come across an announcement made in July 2022 at the time of the launch of the ICB and ICS, which offers a puzzlingly different ‘system priority list’:[6] ‘Get people home from hospital / Reduce ambulance delays / Trying to clear the backlog of elective care appointments / Creating a sustainable workforce across health and care services / Expanding support for people with mental health needs, learning disabilities, and autism / Increasing dementia diagnosis rates and improving support for people, their families and carers once a diagnosis is made / Reducing health inequality.’
The two lists have some common elements. ‘Flow’ in the PwC list matches with ‘Get people home from hospital’ in the System Priorities list. Dementia features in both lists, as do clearing the backlog of elective care appointments and support for people with mental health needs, learning disabilities and autism.
What stands out is that according to the PwC report, between July and November 2022 ‘reducing ambulance delays’ and ‘reducing health inequality’ were dropped from the ICB’s list of priorities.
These are crucial matters, especially at the present time. Ambulances held in queues waiting to discharge patients into the Emergency Department at Treliske (Cornwall’s main acute hospital) have featured regularly in the media. Health inequality/disparity gets less attention, but the Health and Care Act 2022 requires integrated care boards to have regard to the need to reduce inequalities between persons, not just patients, in respect of access to health services. Government guidance says the integrated care strategy should ensure that the needs of underserved populations are identified and met through the integrated care board, NHS England, or responsible local authorities exercising their functions.[7]
One such underserved population in Cornwall comprises the residents of Penwith, in the far West of the county, whose two community hospitals, which used to provide reablement services for local people who had been operated on in Treliske, have both been closed by the ICB’s predecessor, Kernow Clinical Commissioning Group, in recent years.
Another underserved population is that of older people who are experiencing loss of hearing because of earwax. In the past sufferers have been able to depend on their GP surgery for earwax removal, as specified in the NICE quality statement on the subject,[8] but this is no longer the case. To quote NICE,
Earwax build-up can cause hearing difficulties and discomfort, and it can contribute to outer ear infections. … Hearing loss caused by impacted earwax can be frustrating and stressful … [and] contribute to social isolation and depression. Providing earwax removal closer to home, in primary care or community ear care services, will prevent the inappropriate use of specialist services.
There is ample evidence that withdrawal of the earwax removal service from Cornwall’s GP surgeries is discriminating against thousands of patients, the majority of them elderly. There is no indication from their report that the PwC team gave any thought to whether the ‘governance’ of the ICS should enable it to identify and respond to inequalities and disparities such as this.
Q4. What could and should the PwC team have done differently?
A. Here are two suggestions: They could have considered what would be involved in joined-up thinking, integrated decision-making and collaboration among separate organizations; And they could have given thought to how citizens, the public, might be engaged in decision making.
Joined-up thinking, integrated decision-making and collaboration. It is widely recognized that within the NHS apportioning responsibilities to organizational units can lead to their becoming self-contained, boundary-marked ‘silos’. The PwC team treats preventing this as a matter of leadership, behaviours and culture. ‘A consistent theme from our work has been the difficulty of relationships with partners in the system’: ‘The strategic priorities need to be socialised and agreed more widely to help instil clarity and facilitate the alignment of activity with the key areas of focus for the ICB.’[5]p.8/12,12/16
An alternative, practical approach to overcoming difficulties in relationships among partners would be to set up working parties across their organizations to examine what actually happens to patients along the ‘journeys’ they take through the system. For example, consider the case of a patient who is taken ill at home, phones their GP and on their advice calls 999, is taken by ambulance to a hospital emergency department where the decision is taken to admit them, then following diagnosis receives treatment, then is moved to a recovery ward, then discharged to a community hospital for reablement and continued recovery, then finally returns home. A working party drawn not from ‘leaders’ but from staff on the ground across all the organizations involved who do the day-to-day work and between them cover all of those stages, could be given the task of identifying hold-ups in the process and putting forward suggestions for removing them. Identifying and assigning such tasks would be a way of developing collaboration.
The PwC team might have pointed out that the approach so far adopted by the leaders of the ICB of getting partners and ‘stakeholders’ together and urging them to reach ‘consensus’ suggests that they are unaware of the danger of lapsing into ‘groupthink’, a situation in which priority is placed on identifying the dominant view and minimizing conflict: critical thinking and the presenting of alternative proposals are not encouraged or rewarded, and pressure is applied to silence dissenters and anyone who is not prepared to conform to the dominant view and support it publicly.[9]
Citizen engagement in decision making. The PwC report has little to say on this matter, but does observe here and there that thought needs to be given to it: ‘For example, at what point does citizen engagement occur and when during the process?’ Note the underlying assumption that citizen engagement will occur at a ‘point’ – to be decided, no doubt, by the ICB.
Recent experience of citizen engagement in Cornwall over the Sustainability and Transformation Plan,[10] and the closure of a community hospital in St Ives[11] has demonstrated that citizen engagement cannot be controlled once people know what is going on. This is invariably uncomfortable for the authorities, but efforts to tame it are rarely successful. If citizens are indeed to be put first, as the ICB says it intends, and especially if groups of citizens find themselves competing for resources, the decision-making process should be completely open to view.
Citizens must know what is going on, if we are to stand a chance of influencing the decisions and actions of the bodies that run our health and social care services.
PS Should you ask management consultants to design your integrated care system?[12]