A year of integrated care systems: Dorset

The Dorset ICS covers the whole county, from the rural west (including Dorchester) to the more urban east (including Poole, Bournemouth and Christchurch). It has a population of over 800,000 with a high proportion of older people and a lower proportion of young people than the national average. Life expectancy is generally higher than the national average.

The ICS built on the STP, which in turn built on the Dorset clinical services review, which has been developing a set of plans for the organisation and delivery of health services across Dorset. This began in 2013 with the launch of The Big Ask – a public engagement process that received 29,000 qualitative comments about services. The NHS partners started working together before the national ICS programme by signing the Dorset NHS System Collaborative Agreement, 2017/18 to 2018/19. This set out shared performance goals, a financial system control total for Dorset and plans to deliver this.

Building on work that has been under way for a number of years demonstrates the commitment to system-wide working that characterises the ICS. The ICS is co-terminous with the STP and both are underpinned by a single CCG for the county. There are three acute foundation trusts, one county-wide community and mental health trust, an ambulance trust and four local authorities. There is a process under way to further consolidate local authorities in Dorset with the creation of two – one for Dorset County and one for Bournemouth, Poole and Christchurch. All of this reflects the close working relationships and the desire of participant organisations to work together for the benefit of the whole population of Dorset across the public sector.

ICS structure and governance

The Dorset system works at four levels, with each having different functions and serving different populations. GPs lead 13 localities each covering a population of approximately 30,000 to 50,000 and are focused on developing primary care networks supported by a shared care record and integrated estates, workforce and population data. The second level is the health and care partnerships – one for the west and one for the east of the county, each serving a population of 300,000 to 500,000 – focused on bringing together integrated community teams spanning primary care, community services, mental health, social care and the voluntary sector. They are also working on designing and delivering a new model of acute care, including changes to the configuration of service delivery mechanisms and locations. The ICS covers the whole population and oversees and implements a single operating plan, sets system priorities and drives operational performance, co-ordinates system-wide population health management, and helps to standardise pathways across the integrated provider alliances.

A systems partnership board includes leaders from all partner organisations who have joint accountability for the delivery of the population outcomes. Underneath this is the system leadership team, which is where the senior responsible officers and the two specialist functions of finance and clinical operations meet. This is supported by the portfolio management office, led by the chief system integration officer, who is also an executive member of Dorset CCG.

A key aspect of the ICS’s work has been the development and introduction of a single financial control total, which the local partners agreed and implemented in advance of this being formally agreed by the national bodies.

ICS priorities

The ICS focuses on five key ‘portfolios’:

• prevention at scale

• integrated community and primary care services 

• one acute network

• digital

• leading and working differently.

Development has occurred at locality and place level – for example, with the work on the integrated community and primary care hubs. It has also happened at the system level, where real progress has been made on the Dorset care record and system-wide control total. In both these cases, collective decision-making has facilitated positive evolution of the initiatives where working as individual organisations would not have had similar success. This demonstrates the benefit of close working relationships to deal with some of the real challenges involved in transforming local services. The ICS also has a clear set of next steps, including changes to the acute sector, which is a further example of place-based and system-wide working – in this case, building on the clinical services review.

Stakeholder engagement

The clinical services review (see above) was based on a significant patient and public engagement strategy where clinical models developed by clinical working groups were tested by public and patient engagement groups. The ICS has built on this approach to test other changes and proposals made across key portfolios. This is helping to embed engagement as a key element of the ICS’s way of working. There has also been significant engagement through local authority members, which has added to the sense of local ownership of the work.

Key enablers

The features that have facilitated progress in Dorset include:

• a significant history of collaborative working supported by a prior collaborative agreement, a single CCG, co-terminous local authorities working closely together and a provider alliance with common objectives

• senior leaders with history in Dorset and credibility nationally, with a set of strong and positive working relationships that allow both support and challenge

• a clear vision and shared objectives among all partner organisations

• progress with system-wide initiatives, including the single control total and the single Dorset care record, demonstrating what can be achieved

• a stable performance position in terms of national access standards and similar financial positions across all providers.

Next steps

Many interviewees commented that there are some very practical next steps for the ICS. These include progressing the merger of Bournemouth and Poole hospitals, which is seen as an important stage of the clinical services review, and new acute models of care. Some interviewees also identified a merger of the local authorities as a practical next step. In addition, there are service changes that are in progress and interviewees described further work to embed these. This includes the rollout of the Dorset care record and the implementation of community and primary care integration in the localities. Both of these initiatives have received significant financial and other support from ICS partners, so seeing positive progress in terms of delivering objectives is a key next step. Managing the financial challenge in 2018/19 underpins a number of these programmes and will be a priority for the ICS. Interviewees also highlighted engagement with patients, the public and staff as a priority going forward.