“Collaborative working is an absolute must” Felicity Cox on improving inequalities in integrated care systems

Last week at IH, we had the pleasure of speaking with Felicity Cox, chief executive at Bedfordshire, Luton and Milton Keynes (BLMK) ICB. Felicity discussed her role, background and experiences working in the NHS, and the ever-evolving landscape of integrated care.

Background and current role

I’m a qualified pharmacist; I started my career as a community pharmacist. I’ve done some NHS-based management consulting, I’ve worked for NHS England as the commissioning operations director for Kent, Surrey and Sussex, I’ve been a primary care trust chief executive, I’ve worked in the specialised commissioning directorate national team – but I started my NHS corporate career in Bedfordshire, Luton and Milton Keynes. I love this part of the world and I maintain my registration quite deliberately because it keeps you in touch with where you’ve come from. It’s always good to remember that you’re a clinician.

I was appointed executive lead for the ICS in September 2020. I became accountable officer for the CCG in January 2021, chief executive designate in November 2021, and from there I became the chief exec.

Main focuses and responsibilities

The ICB is responsible for the planning and delivery of all services across BLMK and as chief executive, my job is to make sure that happens.

As a board, we are really ambitious for the health of our population and we really want to make a difference to healthy lives lived. Tackling health inequalities is a key priority – we’ve undertaken a review of health inequalities, and I’m also the regional lead for this area, so that is very much our drive.

At present, we have a 19-year gap across our population in the amount of time you spend in ill health as opposed to good health. I can stand in one point in Luton and if I walked within 200 yards either way, there would be a 10-year drop in life expectancy. If you take a 10-minute journey on the bus from Bedford villages into Bedford town centre, the difference will be about 12 years. It’s really significant.

Another main focus is around our workforce, not just in terms of the ICB, but in terms of the whole of BLMK. It’s about how we can create pathways into our workforce, and how we can link NHS careers with social care careers.

Data and digital is a huge priority – because the nationally given responsibility of an ICB is to improve the health of the population, it’s really important that we can track that carefully. Health service data is one thing, but that only tells you if someone has had an episode of illness. Tracking the health of the population requires the linking of different data sets, so we’re spending a lot of time on that.

Another important part of our data and digital strategy looks at how we can keep people well in their own homes, including remote monitoring, so we can spot if someone is not as well as they should be. We’ve also put a lot of investments into care homes, supporting them to keep people safe.

Key factors for developing the ICS

The absolute must is collaborative working, and that’s not as easy as it sounds. We’ve got to collaborate, we’ve got to integrate, we’ve got to think about all the factors around collaboration and integration and make sure that people feel safe in it. People often feel quite safe in their own organisations and governance, but working in an integrated way with somebody else’s governance can feel quite challenging.

We’ve got different objectives in the health service compared to the objectives that a local authority or social care would have, and we’ve also had about 20 years of competition in the NHS rather than focusing on collaboration.

We need to do joint planning, we need shared decision-making, and we need good information-sharing to underpin that.

“We tend to compartmentalise patients… if we are to improve the overall health of our residents, we’ve got to be population-centred.”

Another factor focuses on looking at somebody’s life as a whole. We talk a lot about whole systems being really important, but actually, we need to look at the whole patient pathway too. We tend to compartmentalise patients into hips, knees, colds, coughs, sore throats, appendicitis, etcetera. If you look at things which are less physical, like mental health, quite often that is the product of a range of other factors that might have nothing to do with their physical health status. We need to think about our residents as the centre of our world – yes, the NHS should be patient-centred, but if we are to improve the overall health of the residents, we’ve got to be population-centred.

One of the things that is really important to me is how we can get the NHS to really step into being an anchor institution. We need think about what we can do to grow the wealth of the population, in the knowledge that wealth is really connected to health. Why aren’t we buying as many of our goods from our local population as we can, to keep money circulating within our local system? Why aren’t we working to draw as many of our staff from the local population as possible?

We’re a place of really high growth – three out of four of our local authorities are the highest-growing in the country. We grew 15 percent last year. It’s important that as people come into our systems, we can keep them local with great opportunities available for them. It’s not just about being patient-centred, it’s also about being resident-centred.

Key benefits of the ICS

For me, it comes back to looking at the whole person and examining all factors surrounding their health.

I talked about joining data together – we’ve got populations with higher instances of COPD and breathing issues, so we can now join data together to look at their pollution exposure, their home life, the level of damp in their houses. It enables us to pull all that information together and see what requires focus. We can plan better – for example, this winter, we’ve invested in warm spaces which leads to people keeping well, out of hospital, and reducing the respiratory problems that would have arisen if they hadn’t had that warm space.

The opportunity to look at the range of factors impacting a person, especially in the voluntary sector, is a huge benefit. They can really tap into people that we can’t necessarily reach all that easily. For example, we’re doing a good piece of work with MK Dons, a local football team. They are offering coaching and mentoring to children from deprived backgrounds in two of our most deprived boroughs in Milton Keynes. It plays an enormous part in contributing to their physical and mental wellbeing. Through the voluntary sector, we can also tap into things like supporting mental health crisis cafes and befriending support for people with mental health issues.

Then there’s our university partners – we’ve got robotic delivery of medicines happening at Milton Keynes Hospital in partnership with Cranfield University, for example.

One of the great benefits of the ICS is that various partners can gather round the table and use real convening power. We were recently asked for our definitions of the ICS, and all the chief executives gave different definitions. I said that it’s about everyone who lives and works in this part of the world; how can we make the most of the different people, skills and experiences available to us, to help them.

Challenges around developing an ICS

We have a rapidly growing population and that means changing needs. Take housing growth, for example. Over the last 10 years we’ve had 5,000 homes built and another 6,000 expected to be built over the next 10 years. We are growing quickly so that creates a lot of extra demand for us. Keeping pace with population change is very challenging. 

As I mentioned, we’ve got a lot of deprivation in our communities, and with that comes a high prevalence of long-term diseases, so that’s a major challenge.

The other thing which is both a challenge and a joy is the diversity of our communities. When the push was on for COVID vaccinations, we discovered in certain areas of the population that we needed to go hyper-local. We were one of the first ICBs to take vaccination buses into supermarket car parks and do family vaccinations, because we knew from insight into the population that some cohorts are less likely to have the vaccination themselves unless they see a family member having it too. We started to ask for forgiveness not permission around what was the best way to serve our population. 

In terms of partnership, I’d say that one of the big challenges is the range of partnerships available – how do we harness everyone?

Measuring impact

We’re trying to move away from the NHS’s tendency to use activity measures such as how many GP appointments are delivered.

We’re in the process of delivering our outcome measures at present – our key impact focus is on the life expectancy health inequalities that I mentioned earlier. How can we improve the healthy life lived for the people at the lower end of that 19-year life expectancy gap, whilst maintaining the good life expectancy for the people at the other end of the spectrum? It’s challenging, because governance works in five-year cycles and changes in life expectancy work in ten or twenty year cycles. But we want that to be our big focus measure.

We’re looking for interim measures in the meantime, focusing on outcomes, not inputs. We’re looking at avoidable deaths for treatable conditions, improved mental health and wellbeing, how can we modify people’s lifestyle choices and behaviours – shorter term impacts, but still quite a challenge.

Key opportunities for the ICS landscape

One of the key things about having broad access to a range of partners such as the voluntary sector and local authorities is the fact that they can help us talk to and with people that we don’t tend to hear from. We’re doing some good work with the University of Bedfordshire to work with our Gypsy and Roma community, and working with community leaders to expand networking with Muslim women, for example.

I think there’s an opportunity around tackling obesity in particular. It’s a huge challenge and one that is going to drive healthcare systems across the UK but certainly across quite a lot of the developed world as well. If we can’t tackle that, sustainability is going to be a challenge, because people aren’t going to want to pay the amount of tax that it would require to keep an obese population healthy.

The opportunity is the ability to gather partners around every stage of people’s lives – for example, if obese mums and dads have obese children. Where do you start, where do you break that cycle? Partnership gives us the best opportunity to get into education, for example, into schools and clubs.

Ultimately, we need to find motivators for people to modify their behaviour, to recognise the factors in a person’s life that are making this happen. We’ve got to find really individual ways to tackle that obesity challenge.

Hopes for the future

I would like to see a future where people don’t notice the joins in our system; for integration to be normalised, so people don’t know whether they are receiving help from the social or voluntary sector, they just know that they are being looked after and they have got what they need. On this note, I would also make the point that co-location is not integration; sometimes people think that if you put them in the same building, it will somehow work out, but working together has got to be a conscious decision.

If I was looking at a board meeting in 18 months’ time, I would really like to see us spending 80 percent of the time talking about the wider determinants of health and what we can do together.

I’d like to see more work with the voluntary sector; their expertise and ability to reach people we don’t is phenomenal and underutilised.

I’d like to see us really designing services with the population because co-production being so important at every level. How do we hear the seldom heard? Individual and service co-production would be a really big win for all of us. You can design services to be efficient but not effective, but if you can get the patient voice into the design, then you can achieve effectiveness as well as efficiency.

Thank you so much Felicity for joining us. If you work within an integrated care system and you would like to share your experiences, please email jessica@htn.co.uk.