Among the rays of hope over the past 12 months were the examples of local organisations coming together to face the challenges of the pandemic as a co-ordinated system. Our two previous reports on system working in London, published in 2017 and 2018, attested to the sometimes difficult birth of sustainability and transformation partnerships (STPs), which have since evolved into integrated care systems (ICSs). Our latest report on the progress of system-working in London highlights the progress made since then. It was researched partly before the arrival of Covid-19 and partly after the first wave receded. Even in the work before the pandemic it was clear that there had been real progress in joint working in many parts of London. While this was not uniform, there was evidence that leaders had learnt from the previous shortcomings, with greater emphasis on involving clinicians, patients and better public involvement in the development of the 2019 (ie, pre-Covid) system plans. In particular, we found that local authorities had been much more closely involved, with strengthened relationships and trust between many local leaders. Though still emergent, there was also progress on governance and transparency, again a problem area in 2016.
System-working greatly accelerated through the first wave of Covid-19. A strong sense of common purpose and a focus on just getting on and making practical changes to services, joined to the suspension of some of the previous barriers to joint working meant many could point to the real improvement in integration and the benefits it brought.
Since then there has been another surge in Covid-19 and the country is engaged in the biggest mass vaccination programme in our history. As the numbers of Covid-19 infections recede once again minds will turn once more, to thoughts of recovery. It’s a daunting list that includes exhausted staff, a surge in the need for rehabilitation post-Covid, growing waiting times and the mental health side effects of extended lockdown. While the gains made in better integration could and should help confront these new challenges, system-working is still fragile and recent progress is not yet locked in. To embed the gains there will need to be a continued focus on shared purpose – delivering tangible improvements to services; continuing to focus on the relational aspects of partnership working and developing governance and structures to underpin collaborative working while improving transparency.
The prospect of legislation may help provide stronger underpinnings for collaborative working at ICS level, but even this needs caution as the real action on integration occurs at place, which in London means the borough level. The interest in ICS structures shouldn’t distract from the need to enhance and build on this work at place and the key role for ICSs in supporting these place-based relationships.
Realistically, it is likely that some barriers suspended during the pandemic will resurface, whether due to financial challenges (which are already very deep in local government) or a return to top-down performance management in the NHS in the face of long waiting times. These are added to the existing systemic risks to London’s health and care services arising from workforce shortages and the fragility of the social care sector. Yet better system-working should be part of the wider plan to address these challenges, a wider plan that will also be able to draw on gains made during the Covid-19 period including the dramatic switch to remote working and the use of technology.
Some of these gains arose because there was a sudden burning platform of common purpose across the health and care system. This is consistent with the evidence from our forthcoming work on place-based partnerships: that common purpose and going where the energy is really helps cement better joint working. The heavy losses of Covid-19 may continue to provide this sense of purpose even as virus recedes because they so tragically underlined the depth of health inequalities in London as it did in the rest of the country. Many of the system leaders we interviewed in London spoke about the need to seize the moment on reducing health inequalities with renewed energy and determination. Turning this aspiration into action could provide exactly the unifying purpose that London’s health and care system needs.