Harnessing the winds of change – early learning on integrated care systems

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Part of Integrated care systems

On a recent sailing holiday in the Greek Islands, we met the Meltemi winds – blowing hard from across the Aegean Sea. So, I spent a week rather than the planned few days on the island of Sifnos. This would not have mattered (so much) if half our party on another boat had not already reached our planned final destination – a comfortable and rather spacious house on the beach at nearby Serifos. 

Working with a group of leaders from one of the ‘first wave’ integrated care systems (ICSs) the other day, I was reminded yet again of how important ‘local weather’ conditions can be – in this case influencing the nature of collaborative working between staff from four NHS organisations. To date, the work of the integrated care system has been held by a small group of leaders and a few senior staff from participating organisations. The senior leadership group was discussing how to increase local capacity for system working. There was recognition, as in other ICS areas, that other groups of staff such as clinicians and middle managers must become more involved to achieve the desired changes in patient care and population health.  

Berkshire West ICS has already started to highlight the importance of system working in staff appraisals, setting individual objectives around the work of the ICS. Organisational board meetings in this ICS area – like others in our research – are systematically paying more attention to ICS activities. So, what else can be done to create more favourable conditions for others to become more actively engaged in collaborative working? And, how do we do this while recognising that many staff are already over-stretched by their current workload? 

In our short time together, we generated several conclusions and ideas.

  • One suggestion was to use the ICS label more widely both within and outside the collaborating organisations. 
  • Some felt that using the ICS acronym was unhelpful and that a better way to engage other groups of staff would be to clarify the purpose and perceived benefits of why organisations were now working together rather than competing for resources. 
  • Everyone agreed that it would be helpful to introduce some new system-wide metrics for performance. 
  • Some participants saw developing local system metrics as an important first step in resetting the relationship between themselves and NHS Improvement and NHS England. 
  • The continued focus by regulators on organisational rather than system-wide performance has been difficult for ICS and other areas wishing to adopt a more system-wide or place-based focus.   

Our new research report, A year of integrated care systems: reviewing the journey so far notes that many of the first wave ICS areas welcomed the more permissive environment granted by NHS Improvement and NHS England. Some have identified the need for ‘a stronger steer’ from NHS England, akin to the focus given previously to the foundation trust application process, recognising the high level of resources locally now going into collaboration.       

Personally, I think greater prescription from NHS Improvement and NHS England will have limited value. There are considerable benefits from good collaboration – increased energy, enthusiasm, and an appetite for bold action on complex issues to secure tangible change for patients. But these benefits depend on the right environmental conditions for allowing staff to harness the winds of change. System leadership groups at a national and local level have an important role in defining such conditions.  

Shifting from a competitive to a more collaborative mindset has not been easy and paying attention to the past has been an important part of the journey. Many first wave ICS leadership teams are functioning well and taking a collegiate approach. Most have spent time clarifying their shared purpose for working together and are now beginning to shape key business processes to support greater collaboration across participating organisations. Examples here include making complex decisions about managing financial resources and redesigning services.  

To avoid individual and organisational interests pushing too hard on such important system-wide decisions, new and different spaces or forums are being created. These enable sharing a range of different stakeholder views, and managing any inherent tensions so that the best decision for the system can be reached. External facilitation may be helpful initially to shift the conditions towards a more inquiring approach, for gathering a range of diverse views to inform decisions.    

Critically, designated ICS leads – like yacht skippers – will need to work with other leaders and staff groups to ‘chart the route’ and secure the commitment needed to reach the agreed destination. In this case we are travelling towards improved health and care services for local populations.

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