North by North West: The place is the thing

Cheshire and Merseyside’s integrated care board has been motoring ahead with its leadership arrangements, having already chosen its “place directors” and published detailed charts of its directorates.

In larger health systems, like C&M, much is going to rest on the relationship between the ICB chief executive and the nine place directors overseeing each borough.

C&M has promised a “majority of ICB activity” will happen at place level, which suggests the place directors will be bulky and important posts.

But note the word “activity”, as opposed to “decisions”.

These roles do not hold the status of “accountable officer”, and those holding them will ultimately be answerable to the ICB.

This could prove a tricky shift for those place directors who are currently accountable officers for the local clinical commissioning group, although it could help that their new boss, ICB chief Graham Urwin, has sort of been their old boss for several years, as performance director for NHS England.

Conflicting priorities

In three of the C&M boroughs – Sefton, Cheshire West and St Helens – the place director will be a senior local authority official. In theory, this should help advance the integration with social care, which is probably the most important priority for the NHS.

But it could also bring difficulties down the line. In Sefton, for example, there are very likely to be plans put forward in the next few years which could substantially change the configuration and extent of acute services offered at the hospital site in Southport.

Any plans to reduce or downgrade those services will be highly contentious, with the council likely to oppose them.

This would leave Deborah Butcher, the ICB place director and director of health and adult social care at Sefton Council, potentially being jointly employed by one organisation that’s pushing for reconfiguration, and another organisation that’s fighting it.

No skewing

Last week’s edition highlighted the very low volumes of elective activity carried out in Greater Manchester over winter, by using NHS England’s method of comparing activity to the last winter before covid.

Some readers fairly pointed out the numbers could be skewed if GM had reported particularly strong activity volumes in 2019-20, against which the latest numbers would inevitably look bad.

NxNW took another look at the data last week, this time using the winter of 2018-19 as the baseline. This did change the picture for a handful of health systems, such as Lincolnshire, Derbyshire, and Essex.

But comparing the GM activity levels to the new baseline made no difference to its relative performance, with its percentages still ranking as the lowest in England for each of the four months to March.

Imperfect planning

When bed occupancy is above 85 per cent, there is clear evidence that quality of care and patient safety reduces.

It’s been many years since the NHS has been anywhere close to this on a consistent basis, however, with occupancy rates gradually creeping up over the last decade or more.

These days hospitals don’t even plan for 85 per cent, which would not be credible on the current patterns of demand and available capacity.

Hospitals in Lancashire and South Cumbria, for example, have assumed 94 per cent occupancy for 2022-23, which they acknowledge is far from ideal.

Kevin McGee, chief executive lead for the provider collaborative, said: “We recognise that this level of bed occupancy is high, but it is necessary to allow us to deliver our elective service recovery and deal with our waiting list backlog in line with national expectations whilst at the same time managing continuing non-elective pressures, including dealing with ongoing covid-19 demand.”

Plans to improve community and social care services, including an increase in virtual wards, could potentially bring down occupancy in the second half of the year, Mr McGee added.

LS&C’s plans also look extremely vulnerable to any new surge in covid admissions, as they assume covid occupancy of 5 per cent or under from June onwards.

Missing patients

The push to get trusts to disaggregate their waiting lists by ethnicity and deprivation levels is long overdue, and many trusts still appear slow to carry out the work.

The Northern Care Alliance, now led by Owen Williams, who has pushed this agenda nationally, is among a handful of large providers to release detailed data, although it reveals some difficulty in analysing the situation.

The NCA data suggested patients from more deprived areas, or from ethnic minority groups, were more likely to have shorter waiting times; the opposite of what we might expect.

But the trust said this could be explained by the reduction in additions to the waiting list throughout the covid pandemic, because the overall proportion of patients added to the list from the most deprived groups fell in 2020, while the proportion of all other groups increased.

The trust said: “This could partially explain the reduced median days on list for the most deprived decile compared with all others.”

Meanwhile, patients from more deprived communities had, on average, been categorised as higher priority, which could be because they have been added to the waiting list later, and in a more severe condition, the trust added.

A new CEO

East Cheshire Trust has advertised for a new chief executive, following the formal departure of long-standing leader John Wilbraham.

This suggests the board is not currently seeking a joint leadership model with the Stockport and Tameside trusts.

With Stockport still in the process of being stabilised, the window of opportunity may have just come too early. Clinical integration between the trusts will continue, however.