Making the goal of integrated care a reality?

Announcing the government’s invitation to local organisations to apply to become pioneers of integration, Norman Lamb MP emphasised how crucial this initiative is. But will the pioneers be given the freedoms and flexibilities to overcome the current challenges they face? And how can we ensure that this initiative promotes the transformation in care and support services that we need to meet the demographic challenges and changing patterns in disease? 

At our recent integrated care summit, one of the key policy challenges identified was the current contractual and commissioning arrangements for primary care and the importance of redesigning the current model – a highly topical issue at the moment. Under the new arrangements, commissioning of primary care services is the responsibility of the local area teams of NHS England, not the local clinical commissioning groups. Some CCGs believe they need more direct involvement in the commissioning of these services if they really are going to make a difference and offer an enhanced level of service within a primary care setting. At the summit various ideas were discussed – some CCGs suggested they use their pioneer application to take on the delegated responsibility for commissioning primary care services, within a framework agreed with their local area team. Others felt they could work closely with their local area teams and place contracts with a group of GP practices, or in some instances use the flexibilities of the current personal medical service contracts. 

Another group of challenges facing local NHS and social care organisations who are wishing to implement integrated care at scale and pace are a variety of technical challenges, such as payment mechanisms, contracting, governance arrangements and regulation. Pioneer sites will have the opportunity to work with a range of national organisations, such as Monitor, to remove some of these technical barriers. For example, pioneer sites may wish to explore payment systems that reward continuity of care across organisational settings, rather than activity-driven contracts, something we have promoted as a potential development of payment systems in our paper on Payment by Results. Others may wish to challenge the current regulation rules on procurement and a range of other regulations that appear to support organisations rather than systems of care. 

However, although overcoming these challenges is important, from our work with a range of different localities across the country, we would argue that integration of care in itself is not a technical or a policy challenge, it is much more of a leadership challenge. If pioneers are to successfully implement integrated care at scale and pace we will need to see changes in behaviour and, in some instances, a significant shift in organisational culture.

Local leaders have an extremely important role in developing the vision for integrated care and demonstrating commitment to working together to improve services for a defined population, as we explored in our paper on Making integrated care happen at scale and pace. But, perhaps more importantly, they must model more collaborative behaviours to those delivering and managing services. They will also need to focus on what best meets the needs of their local populations rather than of their individual organisations. Different types of conversations and decisions will be needed by leaders to remove the disincentives for integrating care. Health and social care leaders in many areas such as Manchester, Bradford and Cornwall are now meeting and starting to engage. 

The implementation of more person-centred co-ordinated care will also require greater teamwork among clinicians and managers – in many instances this will require shifts in working patterns and shifts in mindsets to successfully work across different care settings. In some localities, action learning sets have been formed to bring professionals from different organisations together – allowing people the space and time to work through issues together. In other instances, more formal leadership development programmes to equip clinicians and managers with the necessary collaborative skills and behaviours will also prove beneficial. Systems and processes will need to change, but it is perhaps the shift in behaviours that is perhaps the most important. For ultimately it is the actions of the staff working in and with the health and social care organisations that will make the goal of integrated care a reality. 

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