Integrated care systems (ICSs) and provider collaboratives are ushering in a move towards more collaborative working across organisations in health, social care and the voluntary and community sector – and digital health technologies have an important role to play. Digital technologies can help information and communication to flow across organisations, people and places, bringing benefits for both patients and staff, eg, fewer tests, improved patient safety, reduced costs and saving both patients and staff time. However, using digital health technologies to overcome silos, often referred to as interoperability, has been a longstanding challenge.
We undertook research to understand how to progress interoperability in health and care. Our research combined a literature review with interviews and workshops. The workshops helped us to test a methodology around how to build and strengthen relationships to help improve interoperability. We drew on the experience of two ICSs – Cambridgeshire and Peterborough ICS and Humber and North Yorkshire Health and Care Partnership – as case studies to share how practical solutions can address the challenges ICSs face.
We concluded that there isn’t an agreed consensus on what interoperability is, but we define it as how people, systems and processes talk and work together across organisational structures and professions, supported by technology.
Digital health interoperability has traditionally been considered a technology problem. We found that good technology is not enough for interoperability to succeed; relationships between staff and organisations are vital for success. Staff who do not work well together tend to control digital technologies and medical information in a way that hinders sharing and collaborating. We heard that leaders who prioritise building relationships across organisations view digital tools as an extension of these relationships which in turn helps interoperability. A singular focus on technology overlooks the importance of the people using the technology and the environment in which the technology is being used.
Three factors feed into the success of interoperability projects (see Figure 1).
- Relationships based on trust between staff and leaders.
- Technology that makes communication and medical information flow as easy as possible.
- An enabling environment that provides sufficient long-term funding and targets that support collaborative working while developing complementary workflows across organisations.
The health and care system has historically worked in silos; staff and leaders have an imperfect understanding of the difficulties, frustrations, pressures and priorities of their colleagues in different organisations. Without understanding each other better, staff and leaders can find it difficult to work together to achieve a common goal. This can change if organisations and the staff within them build and strengthen their relationships and trust. This is not a one-off activity but an ongoing process needed as staff, and their roles and responsibilities, change.
Power dynamics across an ICS – driven by varying organisational budgets, size and activities, and perceptions of different professions – can prevent cross-team working. Investing time and energy in building relationships and strengthening trust can help to minimise power dynamics.
Leaders also need to have trusting relationships with their peers across organisations to help them lead collaboratively as equals. This challenges traditional leadership approaches but is necessary as integration and interoperability can result in unequal distribution of risk, cost and benefit across organisations.
We learnt it’s important to work with staff to develop and deliver interoperability projects. It’s also important to identify staff who can act as ‘champions’ to support, engage and motivate staff through professional peer group relationships. Champions can help to lead interoperability projects, ensuring they fit with the expectations of the professions concerned while addressing the immediate needs of staff.
Our research found technology fragmentation – organisations using different software and hardware with different capabilities, functions, information captured and formats – is an issue. Fragmentation limits how much staff across organisations can work together and share medical information to improve care services. Fragmentation is also present in the inconsistent way that data and digital standards are applied to different frameworks and accredited supplier lists. The inconsistency means there is no whole-system approach to interoperability standards, so
compliance in one part of the system is not matched in other parts of the system.
Health and care staff perceive suppliers as being reluctant to comply with digital and data standards. However, uncertainty on how final a standard is increases suppliers’ reluctance to use valuable resources on making changes based on an unfinished standard.
An enabling environment
Technology and relationships alone are not enough to truly join up services, thereare some wider that need to be in place, including the following.
- Information governance: much information governance is currently risk averse and so encourages staff not to share medical information. For information governance to be enabling it requires a shared understanding of what governance is and how it keeps information secure, protects privacy and manages risks.
- Access to analyst and data science workforce: using data from digital systems requires analytical skills, as well as the support of specialist staff, including analysts and data scientists. However, there is a limited number of highly trained analyst professionals so organisations are competing to recruit and retain analysts.
- Appropriate staff training and skills: data in different systems needs to flow and be understood by staff to be useful. Currently, however, patient information is written, read and, therefore, understood differently by different individuals, professions and organisations. Staff development designed with support from clinical informaticians can help to improve this.
- Sufficient capacity for transformation: organisations need to have the capacity to transform. Too few staff, staff burnout and workload slow the pace of any transformation project. It is vital to give staff time and space to think about, prepare for and engage with interoperability projects.
- Compatible workflows across organisations: adapting workflows is important when adopting new technologies. Disrupted workflows can cause frustration, increase demands on staff, and ultimately prevent effective joint working. Creating complementary workflows across organisations raises questions about who does what, and whether a certain process is good enough, all of which can create tensions between staff.
- Supportive national policies: national bodies influence workplace culture, behaviours, resourcing and technology, both positively and negatively. National technology and data initiatives have a significant impact on interoperability projects in ICSs, for example, the national GP Data for Planning and Research (GPDPR) programme had negative consequences on ICS activities.
- Accessible, long-term funding: current approaches to funding interoperability projects make it difficult for organisations and systems to take a long‑term, multi-year approach. Most funding is hurried with a short application timeframe and is relatively short term, often resulting in multiple small short‑term projects that are disjointed, which can create more challenges.
- Targets that support improvements in outcomes: to measure the pace and success of transformation, organisations use a set of targets largely decided by national NHS bodies. It is important to identify and capture metrics that measure the actual impact of change, not proxy metrics. When metrics used to track progress are not aligned with care needs they prevent cross‑organisational thinking and encourage siloed behaviours.
Creating the time and space to work with staff across an ICS is important to build relationships based on trust, address power dynamics and create an enabling environment. In this report we provide a methodology to support leaders at all levels to create a shared space for working with staff that can be used during interoperability projects to support progress (see Figure 2).
Our research shows changes are needed to the technology and enabling environment to help interoperability progress, but that trusting relationships, which are equally important, are often overlooked. There are areas where national bodies can make changes to the context and environment organisations and staff are working in, equally there are actions local leaders can take, all of which facilitate interoperability. Our recommendations for leaders and national bodies can be found in the report.
About this report
The work for this project was sponsored by TPP, a member of The King’s Fund’s Corporate Partnerships programme. This output was independently developed, researched and written by The King’s Fund. The sponsor has not been involved in its development, research or creation and all views are the authors’ own.
Having been involved with my present surgery for over 20 years. I have attended in a PPG role and consider the present period in NHS development is at a critical stage. Attending meetings at Wakefield CCG was very helpful in the past and allowed me to question local changes to medical provision and received assurances which allowed me to pass on information to my PPG. This has been interrupted over the last few years with Covid dominating and at present further local changes are difficult to comprehend.