Early in Ed Garratt’s career, he recalls, he encountered “a view that I might be too kind to be an effective leader: that you’ve got to have a more punitive style, a tougher style.” For many years, he adds, “a pacesetting, performance-management style was fashionable: a competitive, harder edge.”

That approach to leadership is, Garratt believes, “one-dimensional” and counter-productive. “If you want to deliver sustainable results, if you want to generate genuine followship, you’ve got to treat people with respect,” he argues. “What people really respond to is leaders rooted in their local communities, who are giving clarity of purpose and building a sense of belonging.”

Garratt’s leadership style is inspired by that of James Timpson, the business leader and, since July, peer and prisons minister – who sees “kindness and trust” as the best ways to build organisational performance. “Showing kindness and trust towards your staff creates a virtuous circle, because people respond well to that; and then they show those qualities with their staff and across organisational boundaries,” Garratt explains.

Inspiring staff to meet a shared goal, Garratt believes, is far more effective than herding people forwards with individual performance targets. “Establish a focus on the outcome for the community, rather than focusing on the mechanics of how you get there,” he advises. “The importance is in developing the commonality and the culture; that will develop its own virtuous circle, and propel you forwards.”

As chief executive of Suffolk and North East Essex Integrated Care Board (SNEE) since 2019, Garratt has built the organisation around these beliefs. “One of the organising principles of our system is showing kindness – both to our communities and the people we serve, and to our staff,” he comments.

It seems to be working. As chief executive of the three clinical commissioning groups (CCGs) that merged into SNEE, Garratt secured ‘outstanding’ ratings for each of them. His early work leading the integrated care system (ICS) earned him an OBE in 2023; that same year, NHS England’s review of ICSs’ digital maturity put SNEE in top spot. We are currently awaiting the results of NHS England’s ICBs performance appraisal, in which – Healthcare Manager understands – SNEE is expected to do extremely well.

Garratt can’t confirm his ICB’s place in these rankings, but sounds optimistic. He’s come a long way since 2004 when, studying for a PhD in English literature at Cambridge, he “ran out of money and started temping” for the NHS. “I really, really loved the health service and saw so many opportunities in management – then I got offered a job as an administrator, and built it up from there,” he recalls. “It wasn’t planned, but I felt a passion for it.”

Garratt identifies three key factors in developing his management skills: learning from an “outstanding” chief executive in his first job; working on the NHS constitution in 2009; and going through an “aspiring directors course” early in his career. Such courses are thinner on the ground now, he comments, “but good leadership doesn’t happen by accident: you need to develop and support it in the same way as other disciplines in the health service. Greater investment in structured ways of developing people is really, really important.”

SNEE also supports staff to do local voluntary work and build relationships with community leaders, Garratt says: “You get so much more effort and commitment if people feel that they belong in their community and are making a difference.” This collaborative, locally-focused approach is now producing clear results, he adds, citing improvements in life expectancy, inpatient numbers and hospital deaths among people with learning disabilities. This is that virtuous circle in action.“It’s incredibly rewarding for staff to see the difference that collaboration between the different agencies is making,” he adds.

Garratt also sees the unions as key partners: close collaboration with Sam Crane, MiP’s national officer for the East of England was, he says, key to the ICB’s maintenance of morale and forward progress while making the 30% savings in running costs demanded by government during this year and next.

“One of the first things I did was to sit down with Sam to say, ‘Our ambition is that we will not make anyone [compulsorily] redundant during this process, and I want to work with you pragmatically to find a way to deliver that outcome’,” he recalls. The ICB and unions co-developed a programme for voluntary redundancies, reshaping the organisation around them, and “the outcome was that we saw an improvement in staff satisfaction during the year we were making these changes,” says Garratt. “We came through a difficult time smoothly, and were able to continue making progress. Partnership working is key if you want to maintain organisational delivery and performance; it’s a false economy to work without those strong partnership foundations.”

Garratt’s concentration on building partnerships also pays dividends in digital services, where improvements require organisations to share IT systems and information. Here, the engagement of clinical leaders is critical: “Digital is as much about winning hearts and minds as it is about technical implementation,” he says. “We’ve linked datasets between primary care, community services, mental health services, social care and acute – so we’ve got amongst the most developed datasets of anywhere in the country. And that achievement has been driven through clinical leadership around our digital agenda.”

Effective digital reforms, he adds, “invariably involve moving from a more hierarchical culture to a flatter, more collaborative culture, where you’re trying to get the best use of all your skills mix – and where that’s happened, we’ve seen significant improvements in patient satisfaction and experience, in staff satisfaction, and ultimately in outcomes.”

Some of those improvements in outcomes are generated by using population health information to better target services: work to support people with frailty, for example, is reducing the number of falls and hospital admissions. Others come through better information exchange: SNEE has “the highest use of the shared care record in the country – and a third of poor quality outcomes are a result of poor communication in the health service,” he comments. “So we’re seeing improvements in outcomes as a result of actively using shared care records.”

In dentistry, too, SNEE is forming unique and powerful partnerships. The area has “traditionally been a dental desert”, Garratt comments, so the ICB had an underspend. This offered the “potential to think differently and innovatively – and that’s absolutely what we’ve done.”

With the University of Suffolk, SNEE has launched a community interest company (CIC) to provide dental training and services: the university has built and staffed a new dental centre, which the ICB commissions to treat under-served groups such as the homeless, people with learning disabilities, and children in care. Staff are salaried, and the CIC is paid per session rather than per treatment – incentivising a preventive approach.

Over time, Garratt hopes, the flow of qualified dentists, hygienists and dental therapists graduating from the university will water SNEE’s dental desert. Meanwhile, “12,000 more patients within our ICB have had access to dentistry compared to the year before; and in terms of benchmarks amongst the ICBs, we’ve gone from being one of the worst in the country in terms of access – particularly for children’s access – to about the middle.”

“That’s the benefit of an ICB: you’ve got local relationships and partnerships that you can leverage in a way that you couldn’t if you were commissioning from a distance,” Garratt says. The same holds true in capital investments, he believes: asked whether a relaxation of the national rules governing ICBs’ use of capital budgets would improve results, Garratt replies that “we would be spending a greater proportion in primary care and in community services – and I’m clear that that would deliver better outcomes for the population.”

Reorientating capital spending towards primary care “would be a game-changer in terms of integrating more services locally and decompressing systems generally,” he adds. “It’s a huge and important shift that we need to make in terms of financial strategy.”

Given his track record in CCG leadership, his focus on primary care and his ICB’s success in digital, Garratt was an obvious choice to lead a new NHS England pilot programme testing ways to improve general practice. “We’re working with 22 primary care networks [PCNs] in seven different integrated care boards to baseline the community gap within those PCNs, and provide a 10% uplift in resource,” he explains: the money will fund work to integrate primary, community and secondary services; introduce technology to improve productivity; make better use of skills across the workforce; and better understand and address demand.

The programme was conceived under the last government, Garratt explains, but Labour ministers are “very, very interested – and I think if we can demonstrate evidence-based outcomes, it has huge potential to be considered seriously and for learning to be scaled up and improvements to be made.”

Garratt hopes to demonstrate that reforms and investment in primary care can reduce illness and improve health outcomes – taking the pressure off acute services. In his view, ICBs will prove most effective if they shift care provision forwards and down into local communities, using their local relationships and expertise to mobilise public and voluntary organisations – both within and beyond the ICS – around a common purpose.

“Keeping ICBs on task around delivering better outcomes through collaboration, through leveraging all the partnerships they’ve got available to them, is where we need to be: that’s got to be the consistency of purpose,” he says.

For him, the first task is to tackle the worst outcomes: “The health inequality agenda is absolutely at the heart of that.” And the most powerful levers lie in the healthcare frontline, where staff operate within the communities they serve. “The challenges in secondary care are important, but if they overly dominate then I think that’s a huge missed opportunity,” Garratt concludes. “If ICBs’ attention is on communities and neighbourhoods and places, they can deliver really positive, long-term legacy changes.” //