Local systems of care: one of the solutions to the challenges facing the NHS

Diagnosing the challenges facing the NHS is important – proposing solutions even more so.

My thoughts on two particular challenges have converged recently to lead me to propose one potential solution. The first challenge is the continuing difficulty of recruiting to top jobs and the troubling level of executive vacancies. The second is the fragmentation of the provider landscape at a time when collaboration and integration are needed more than ever.

My solution is that providers should work together to form local systems of care, with leadership provided by the most experienced managers and clinicians in the NHS. This is also something that the recommendations of this week's Health Service Journal inquiry into the future of NHS leadership point to. For the avoidance of doubt, this does not mean another top-down reorganisation. Rather, it requires providers to agree how they will collaborate in areas that are meaningful to them and the populations they serve. The establishment of new systems of care is also quite different from mergers and acquisitions, which typically take an age to transact and at best have a mixed record.

Virtual provider networks would be created based on well-thought-through governance arrangements. This would have to be done in a way that didn’t fall foul of competition rules but also defined the scope of the system to be covered by these networks. Neither of these challenges is trivial but both can be addressed if the case for local systems of care is accepted.

The scope of networks is likely to vary from horizontal integration in some areas to vertical integration in others. Both are of course possible and the involvement of independent sector providers is also an option.

Unlike some of the ideas in the Dalton review and Jeremy Hunt’s proposal to create foundation trust chains, local systems of care would be formed by providers working in the same area. The rationale is that it is difficult to provide buddying support at a distance and that for the most part health care provision is essentially local.

The intervention of NHS England and national bodies in Cumbria, Devon and Essex to create a so-called success regime suggests that planning and managing services in the way proposed here has already entered the thinking of national leaders. But it is not only in challenged economies that this approach has relevance. Areas of the country where performance is good would also benefit from such an approach, both to avoid falling into the success regime and to use available leadership talent as effectively as possible.

The creation of systems also offers an opportunity to focus on health and wellbeing, not just on health care. The Fund’s work has made the case for population health systems to be the next leg on the journey of integrated care, with the potential to involve local authorities and other partners. This thinking is reflected in Devo Manc, where the vision is to tackle health inequalities and promote wellbeing by joining up all public services.

In truth, the idea of systems of care is not new, having been put forward in the Fund’s analysis of health care in London in 2013. At the time the idea was greeted with polite interest but failed to gain traction. Since then growing pressures in all parts of the NHS and the speed at which these pressures have engulfed previously high-performing providers mean that it is an idea whose time has come.

This year’s Reith lecturer, Atul Gawande, has described the time we are living in as the century of the system. Making this a reality in the NHS requires a different type of system leadership, as we argued in a recent report. With time fast running out, the priority is to support the most experienced NHS leaders to work in this way as part of a concerted effort to make local systems of care happen.

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Comments

Renewing and re-imagining systems of care at a local level actually occurs all the time in my experience; what is less clear is the degree to which local systems of care can be conceived of as a paradigm-shift. It is too simplistic to imagine that, on a given day, a local health economy can declare that it now possesses a local system of care where one did not exist the day before.

Of more value is the development of progressively larger and more meaningful system working building upon smaller links and models, carefully tested out and clearly measured for the effects of their implementation. CCGs and providers [and let's not forget that anyone who cares for a patient is a provider, not just an acute Trust] need to be working in a mutually supportive way to get these models up and running.

And the only thing which really matters for seeing systems of care last the course is good old fashioned honesty, trust and support. We cannot put too high a price on time spent in developing good, effective, respectful working relationships across clinical and managerial groups, be they provider or commissioner, consultant or carer.

This, as ever, is the crux of leadership in healthcare. Before we can hope to see sensible systems of care, we need sensible leadership based on straightforward, plain speaking relationships. No corporate speak, no radical transformational innovative boat-rocking. Just the development of conversations, the realisation that patients matter more than anything, and an shared commitment to remember that every time we need to overcome sundry financial or contractual problems in day to day NHS life.

More efforts could also be made to engage the local voluntary and community sectors into partnerships because they do offer complementary services funded from other sources. Our website http://www.useyourcommunity.com is a directory that people are using to refer patients onto local community services

My experience in a variety of fields (includng PCG chairmanship/PCT cancer lead) in former eras, showed that it took a few years for organisations (and individuals) to get together usefully to use whatever was the inflicted NHS regime at the time to develop services across boundaries. Just as we got going, everything (and everybody) changed so collaborative working was constantly undermined. The repeated top down re-organisations of the NHS et. al. fit the political timescale but not the practical working one. The thinking here is rational but so dependent on being encouraged, supported but, in a sense, left alone for long enough to do it.

Initial ideas seem ok but the comments display a degree of deja-vu and cynicism; I feel a far more imaginative and radical approach is called for and one that is more inclusive. I would be happy to help on a pro bono basis if I could be of use.