For the past few months, I have been travelling the country meeting ICS leaders. I see the impact they're making and the great work their teams are doing. But I also hear about the challenges they face and the difficult decisions they must make, day in and day out.
There is no doubt they have a tough gig, the Government has tasked ICS leaders with addressing the problems of today – access to general practice, waiting lists for elective care – while at the same time creating a more sustainable health and care system for the future. As our Riding the storm report shows, the path for systems has not been straightforward so far.
ICS leaders are routinely managing day to day pressures, while creating nascent organisations, building relationships with system partners and seeking to make more radical change to how services are delivered. ICBs have also recently gone through significant restructures due to the 30% reduction in their running cost allowance. Money is tight, health inequalities are widening and an ageing population is increasing demand for services, and unfortunately, we know things are not going to get any easier for the foreseeable future. ICS leaders are up for the challenge but do not always have the right levers to deliver the change needed.
The hierarchal and centralised nature of the NHS makes it difficult to make decisions at a local level and the level of expectation and scrutiny, from both Government and local partners, is immense. Against this backdrop there is a risk we lose experienced and knowledgeable ICS leaders right when we need them the most. Over recent weeks, we have seen a concerning spike in ICB chairs and chief executives announcing their departure from these crucial roles (including one region where three chief execs confirmed they were standing down in the space of two weeks). While in most of these cases individuals are going into well-deserved retirement, it's undoubtable that some are beginning to question whether the job they signed up for is the same job they're doing now.
Non-executive and executive roles require a multitude of different skills and attributes. ICS leadership requires an ability to manage complexity, diplomacy and negotiation in partnership working (both within the NHS and outside) and deep knowledge of the local context. We need to do all we can to ensure these skilled leaders stay in system roles, using their experience and expertise to make ICSs succeed.
Leaders are motivated by the four core purposes of ICSs: to improve health outcomes, reduce inequalities, improve productivity and support social economic development. A relentless focus on the here and now, at the expense of some of the bolder and more transformational change required, plus at times a perceived lack of autonomy and ability to act, can take its toll. As scrutiny increases on a valuable but narrow set of targets around access and elective care and progress on health inequalities and prevention which often move slowly, we know some leaders can sometimes feel disheartened. Mounting pressure to manage finances means leaders are again having to be make difficult decisions about services – trying to balance resource, quality and safety, and still delivering on the Government's three shifts for health, something they are well-placed to do, and bringing, innovation, expertise and foresight to their roles. So how can we retain and attract the best leaders?
Firstly, we should empower local leaders and give them the freedom and autonomy they need. While holding them accountable, a more mature and empowering relationship with the centre can give leaders the best chance to succeed. In this, fewer targets in the latest planning guidance was welcomed by the sector.
Secondly, we should ensure all leaders have the right support and training in place, particularly when it comes to the skills needed for system leadership. Historically, leadership support has been targeted at provider leaders - focusing on the specific skills needed to drive change in complex systems is needed. Given the most helpful tools and development opportunities, we can make sure leaders are continually expanding their skillset and ensuring a strong pipeline for leadership. Many programmes are available, including at the NHS Confederation.
Finally, we should strengthen peer support to help leaders manage the complexity of their roles. Leadership can be a lonely place with unique challenges – connecting to others in similar positions can make a real difference in their experiences. Creating and enabling these relationships are at the heart of what we do as a membership organisation and I see every week how it leads to improvement and makes our health and care system more resilient.
