Feature / Tuning in to priorities

On first look, Lincolnshire Integrated Care Board appears to be one of the more straightforward systems formally launching in July. It takes on the functions of a single clinical commissioning group and is coterminous with the county council, which also neatly fits with the boundaries of the seven district councils. It includes just three trusts – one acute, one community and one mental health provider – all with Lincolnshire in their titles. And it will operate as one single place.

But beneath the surface, Lincolnshire faces many of the same challenges as the rest of the country – but also some issues specific to its own system.

‘There are a lot of complicating factors and challenges quite specific to Lincolnshire,’ says Matt Gaunt, director of finance designate for the ICB and chief finance officer of the preceding Lincolnshire CCG.

These challenges include a rural county with 50-mile strip along the east coast that has a significant amount of deprivation and is poorly served by infrastructure, public facilities and even mobile phone coverage. With some richer rural areas too, addressing health inequalities is high on the agenda.

Workforce challenges

Workforce is the other standout issue. The recently established Lincoln Medical School at the University of Lincoln only took in its first students in 2019, with the specific aim of improving the recruitment and retention of doctors to Lincolnshire.

But the lack of such a facility up to this point has contributed to an underlying vacancy rate that is around a third bigger than some other systems and high temporary staff costs. ‘We spend more than double our agency cap,’ says Mr Gaunt, ‘and we are massively reliant on bank and agency.’

Partly as a result of both the inequalities and workforce issues, the system experiences high use of urgent and emergency care services – with up to 40% of the adult population in some coastal communities living with a life-limiting condition or disability – and the higher costs that come with that.

The county also has dispersed facilities, with acute medical services located in three places, which again create difficulties given the relatively small size of the population for the area covered. ‘So we have three really big issues – inequality, workforce and infrastructure,’ he says. ‘And that is driving a lot of my thinking about priorities.’

Difficult to address at the best of times, these issues become harder in the current financial climate. Mr Gaunt says the first task last year was to frame the financial challenge in a way that seemed manageable – separating out those things that could be addressed in the short term and those that would require a slower burn.

Mr Gaunt estimates the system had an underlying deficit of around £100m as it entered the pandemic – about 7% of its £1.5bn allocation. About half of this is tied to longer term issues such as rurality and infrastructure. The other half splits between things that can be tackled by individual providers driving efficiency and those things that require improved service integration through a system response.

For providers, there are a range of operational issues. ‘There are high costs related to the way we operate and the efficiency within our services,’ he says. This is about addressing variation, with clinicians assessing risk, agreeing standards and the clinical thresholds for interventions, and then adhering to them. This is as much a cultural exercise as a technical one, Mr Gaunt adds.

Then there are system opportunities, where pathways across multiple organisations and teams are optimised for the benefit of patients and to eliminate duplication and cost. Or it could involve delivering earlier interventions to avoid people joining the pathway altogether.

Mr Gaunt insists the system is not ignoring its responsibility for the longer term structural issues that need to be resolved. ‘But we are trying to tackle what we can do here and now and breaking the response into manageable chunks,’ he says.

Even so, the challenge is significant given a very tight financial year, with convergence adjustments reducing allocations, major reductions in Covid funding and inflation already exceeding the levels assumed within the spending review settlement.

Mr Gaunt says funding will need to be used to address inequality. But this will involve targeting growth at key areas rather than cutting budgets in one area to expand them in others. ‘It’s the difference between a pilot and a rollout,’ he says. ‘We will always pilot change in areas with the greatest need, because, if we can land it in those places, then we will have the best chance of having an impact.’

Analytics will be vital for targeting interventions in the right place and population health management, for which Mr Gaunt is responsible, will be a key tool.

‘I need to do a lot of thinking about how we build analytical capability,’ he says.

‘Historically, most of our analytics time has been spent on contract management; we need to tip it away from that into more insights about the interventions we can make. We need actionable analytics that let us get under the skin of urgent emergency care usage, for instance, and get to the root cause.’