The King’s Fund report Place-based systems of care argues that providers of services should work together to improve health and care for the populations they serve. This means organisations collaborating to manage the common resources available to them rather than each organisation adopting a ‘fortress mentality’ in which it acts to secure its own future regardless of the impact on others.
The approach taken to developing local systems of care should be determined by NHS organisations and their partners, based on a set of design principles. These design principles are explained in full in the report and are summarised below:
Define the population group and the system's boundaries
In some cases this will be relatively straightforward – Cornwall and the Isle of Wight being obvious examples – but in others it will be more complex, particularly in large urban areas where people move across administrative boundaries to access care and support.
Whatever geographical boundaries are chosen, place-based systems of care should take responsibility for all people living within a given area. Focusing only on one part of a local population, such as older people or people with specific medical conditions, risks creating new forms of fragmentation. The rationale of place-based systems of care is to bring organisations together around the population they serve.
Identify the right partners and services
While place-based systems of care will have a strong focus on the NHS, they should also involve local authorities, the third sector and other partners. This is particularly the case where the aim is to focus on population health and not just health and care services.
Providers must take the lead in establishing place-based systems of care because it is providers who need to collaborate in developing new models of care that are clinically and financially sustainable. Commissioners will need to be involved to develop new models of commissioning and contracting to support the kind of systems that we are describing.
Develop a shared vision and objectives
A shared vision and objectives need to be tailored to the needs of different areas, reflecting the challenges that exist and the level of ambition of the partners. They should build on work done by commissioners and health and wellbeing boards in understanding the needs of the local population, as well as providers’ knowledge of local services.
Their initial focus is likely to be on achieving the financial and clinical sustainability of local services as well as the development of new care models that cut across current organisational and service boundaries. Areas that have more experience in partnership working may choose to focus on the broader aim of improving population health and wellbeing from the outset.
Agreeing objectives needs to be informed by the wants and needs of patients and the public. But in most health systems, we know very little about what patients and the public really want – and at the front lines of care the silent misdiagnosis of patients’ preferences is widespread (see Patients' preference matter). Over time, systems of care must develop more meaningful and systematic ways of gathering and disseminating information about the patients’ preferences.
Develop an appropriate governance structure
Governance arrangements must reflect existing accountabilities while also creating a basis for collective action. To do this successfully, they must be inclusive enough to ensure that those involved in delivering and receiving services are meaningfully involved in decision-making. They must also be strong enough to be able to coordinate the range of activities involved in meeting the group’s objectives – something that is far easier said than done.
Partners are likely to need to cede some of their own sovereignty and agree how decisions will be made collectively – including whether there are some issues over which organisations should retain the right to approve decisions. Our experience suggests that the partners involved should be willing to be flexible about how governance arrangements evolve over time – for example, by including new members or rules.
Identify the right leaders and develop a new form of leadership
Ensuring that the right leaders are involved in managing the system of care at the appropriate level of seniority, including chairs and board members where appropriate, is essential. Much will depend on the strength of relationships between organisational leaders and the extent to which there is mutual trust and respect.
The effectiveness of governance arrangements hinges on the ability of leaders to work collaboratively in an environment where they may have less authority than has often been the case in the past. This requires the development of a new kind of system leadership based on negotiation and influence rather than direction. Leadership of this kind is often best developed through teams rather than individuals, involving a guiding coalition taking responsibility to lead system-wide change.
Leadership needs to extend right through the organisations involved in place-based systems of care and we would emphasise in particular the role of clinical leaders in developing new care models that span organisational and service boundaries. System leadership that is not underpinned by clinical leadership and the engagement of frontline clinical teams will not deliver the changes needed.
Agree how conflicts will be resolved
Agreeing how conflicts will be resolved within the system of care is essential. There should be an emphasis on informal mechanisms such as mediation rather than resorting to legal action.
Wherever possible, conflict should be viewed as a healthy reflection of the state of collaborative working and the ability of the organisations involved to disagree and move on. At the same time, partners should be clear about the consequences for organisations that fail to play by the agreed rules and behaviours of the system.
Develop a sustainable financing model
Conflicts are possible in many areas but especially in relation to how resources are used and distributed. Creating a sustainable financing model for the system of care is not simple and requires commissioners and providers to work together. We have argued elsewhere that this means taking a new approach to paying for care, across three different levels:
- First, local partners need to agree the collective resources available to meet the objectives of the system. In practice, this is likely to mean commissioners of health services and local authorities working together to pool their budgets and commission services jointly.
- Second, commissioners must develop new ways of contracting with providers to align incentives behind the system’s objectives. Our proposed approach is for commissioners of health and social care to pool resources and create a single, capitated budget covering all care for the local population, for providers to manage under a contract extending over a number of years. A proportion of payments to providers within the budget should be linked to the delivery of agreed outcomes. There are a range of different contracting vehicles that could be used to support this type of approach.
- Third, providers of care within the system will need to agree how they allocate resources and share costs, risks and rewards. More important than the technical detail, this will require strong relationships between local leaders willing to work together rather than compete for resources.
The challenge for the NHS in developing more sustainable financing models is the growing imbalance between providers’ incomes and spending. This is something that requires national action as well as the local action that we describe in our report.
Create a dedicated team
A dedicated team should be established to support the work of the system and act on behalf of leaders in implementing decisions. Evidence from other sectors tells us that this is best done by a new team able to focus solely on the work of the system, rather than a team made up of people simultaneously trying to manage the ongoing operations of individual organisations (Govindarajan and Trimble 2010). In the absence of such support, there is the ever-present risk that plans will not be executed, resulting in frustration and loss of commitment.
Of course, new ideas and ways of doing things will only make a difference if they can be successfully implemented across the organisations involved, which means that the dedicated team should not work independently of others.
Develop systems within systems
In working to meet common objectives it is likely that different partnerships will emerge within and across place-based systems to tackle particular issues of concern. For example, one group of partners might work together to reduce demand on urgent and emergency care services, another might focus on the interventions needed to help reduce obesity across the population, while another might focus specifically on improving care for people at the end of life—and some might work on all three.
This means that systems of care must develop ‘systems within systems’ to focus on different aspects of their objectives, drawing on skills and services from across the community. The important task is to ensure that activities of different groups form part of a coherent, mutually reinforcing approach, rather than becoming a disjointed set of initiatives.
Develop a single set of measures
Finally, a system of care must decide on a single set of measures to underpin its shared objectives. This is likely to involve agreeing a small set of metrics to assess the overall performance of the system, as well as how these metrics will be collected and reported – including to the public. A larger set of metrics should also be collected to allow partners to understand how they are contributing to the overall goals of the system and identify areas for improvement.
This should include measures to test whether the system is behaving in a way that aligns with its agreed values and behaviours. For example, measures could be used to see how well teams are collaborating to deliver more coordinated services (such as IntegRATE) or how well shared decision-making is embedded in the way that care is delivered (such as CollaboRATE).
One of the risks in developing systems of care is that of adding further complexity to an already complex system. While this cannot be avoided entirely, the design of governance arrangements needs to be done in a way that minimises transaction costs and seeks to keep these arrangements as simple as possible.