How much stress can a coalition of the willing take?

13 November 2020

Integrated care represents the future of health and social care in the UK. NHS England expects the whole country to be covered by integrated care systems (ICSs) by April 2021, providing better, more joined-up care for an ageing, growing population with increasingly complex needs.

It remains to be seen whether next April is a realistic target; it’s one thing to set up an ICS, but quite another to genuinely integrate services, especially when the people delivering them are stretched to breaking point by COVID-19. But the direction of travel is clear and welcome.

One of the big challenges associated with integrated care is achieving more and better collaboration between health, care and political leaders. And it’s in the spirit of fostering that collaboration that GGI is staging a series of webinars, to explore some of the big themes of integration.

The importance of ‘Place’

GGI began a series of six webinars on 11 November looking at the design principles for systems working, including ICSs and integrated care partnerships (ICPs). This week’s webinar considered the importance of ICPs formed around place in the success of integrated care systems.

As we set out in our positioning paper before the webinar, a place-oriented approach involves NHS bodies, local authorities and other partners working together on planning, generative and transformation programmes and tackling the wider determinants of inequalities. It is not just limited to reorientating health and social care providers. Place should also be where primary care, citizens, the third sector and others can engage with planning and problem solving. This is where care homes, domiciliary services, housing associations and the third sector can be brought in too.

The need for authentic engagement was one of the themes to emerge from this week’s discussion. As one guest said: “We’re anchor organisations and we must have the humility to work together – listening to citizens. They don’t understand why we’re not working together already and we still make things really complicated for them.”

Engagement efforts must be directed towards the centre as well as the local community, according to another guest, who said: “I’ve always been a great believer in asking for forgiveness after the event rather than permission beforehand, but we must be mindful of taking our NHSE/I colleagues with us on this journey. If they don’t understand what we’re doing, they might hit us with more KPIs than you’d believe possible.”

Is legislation needed? Maybe not

ICSs are now the unit of accounting to the centre and for the money there are single control totals to be delivered this year. This requires integration. For us to move beyond the NHS simply talking to itself about integration, system budgets must be developed, risk management and assurance systems must be established, a framework for local delivery of outcomes built. All this must be achieved before any laws can be passed.

Place-based working may indeed be more about relationships than structures, as several people said on our webinar, but coalitions of the willing can only take so much stress. One of our guests said: “Organisations find it easy to come together over a vision. The challenge comes when things don’t go according to plan, or when priorities change with new leadership. At that point, organisations look to protect their own interests and the vision starts to suffer.”

Coalitions of the willing also tend to favour the status quo so when radical proposals are on the table and there are big decisions to make involving big budgets, it’s crucial that they are properly governed.

Legislation might be necessary to take integrated care to the next level but we should not sit around waiting for it – and nor are we. One of our guests, Andy Field, Chairman of Ashford and St Peter’s NHS Foundation Trust in Surrey, pointed to the Bromley-by-Bow Centre, an integrated medical practice and community hub in east London that has built partnerships with a range of organisations and funders to improve the lives of local residents.

Bromley-by-Bow is a great example of a local initiative that has kept its original vision of community regeneration firmly in sight ever since it was first established in the 1980s, uniting disparate bodies with creativity and entrepreneurship for the benefit of local residents. This provides a small-scale vision of what working together towards a goal of population health can deliver. Scaling this sort of initiative up to cover populations of 300,000 is now the challenge.

We could all learn a lesson from this as we head into the choppy waters of formalising integrated care systems. As one of our guests said: “As we design structures and processes we mustn’t lose sight of our purpose. Our focus shouldn’t be on money or hierarchies, it should always be on purpose.”

In next week’s session our attention will turn to the funding of integrated care. If you’d like to be involved, you’ll find all the information you need on the events page of our website

Prepared by GGI Development and Research LLP for the Good Governance Institute.

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