HFMA 2020: system relationships must be built on trust

Frimley Health and Care is one of the more advanced ICSs, having operated a system control total, initially in shadow form, since 2017/18. Speaking to the virtual HFMA conference, Frimley Health NHS Foundation Trust director of finance Nigel Foster (pictured) said that relationships and trust had been more important than formal arrangements. But he also insisted that working as a system did not mean making all decisions centrally.

‘Don’t try to work together on everything,’ he said. ‘A key part of being in an ICS is knowing what each individual member is good at and is focusing on  –  and not try to do everything together but to let individual orgs do what they do best. Give them the freedom to carry on, but come together where there is benefit [in doing so].’

Mr Foster said that working together happened at five different levels in Frimley: at the individual level: in separate communities and neighbourhoods; increasingly at the place level; at system level; and also working across systems.

This did not mean that there was only one strategy across the system. But all strategies were aligned.

Greater system working had already consigned commissioner-provider contract battles to history. ‘That is not how we work now,’ he said. Instead he said the different organisations saw themselves as a family, working together and supporting each other. However, he added that this did not mean that everybody always agreed with each other.

Trust was the defining characteristic in the leadership approach. ‘The Frimley system is quite small – about 800,000 population,’ he said. ‘But that means you can get all the key leaders around one table.

‘It is small enough for everyone to get to know everybody else and build strong and trusting relationships. I am absolutely convinced that the reason the Frimley system has been able to make some really good progress is because of the relationships in place both at the most senior level and at level of individual teams. Trust has been more important to us than formal governance arrangements.’

Speaking from a personal perspective, he said that being a relatively small system had meant it could move quickly – not needing multiple consultations with large numbers of surrounding partners. He said that 80% of what needed to be done could be sorted within the system, with the remainder needing work across system boundaries. And he suggested that provider collaborations were key to working on this 20%.

The system is now thinking through how it needs to change moving forward. Understanding where provider collaboratives are needed, both inside and across systems, is one of five key areas under discussion.

Mr Foster added that the system’s changing requirements mirrored much of the Integrating care next steps discussion paper, published by NHS England and NHS Improvement in November. Other priorities include: further developing place-based working across the system’s five places; understanding what the model of strategic commissioning should look like; the required governance arrangements; and the shared financial framework that would need to be in place.

The ICS is one of only a few nationwide to have operated with a full system control total, which meant all six organisations had to hit their individual control totals last year to trigger the provider sustainability funding. The system already works well on financial matters, with a core finance group bringing chief finance officers and deputies together for regular meetings.

Oliver White, director of operational finance for Frimley Collaborative, which brings together the three local clinical commissioning groups, said that the focus was very clearly on system costs and not how the money flows. ‘Ultimately we are talking about expenditure plans for each area and not the old world of payment by results and tariff expenditure plans,’ he said.

Developing a new financial framework is the next challenge. Mr White said this needed to cover how funds will be shared across the system, enable organisations to take decisions without always having a system discussion first, and to be clear about how disputes can be resolved.