The unenviable challenge facing Integrated Care System leaders in the NHS
For ‘leading’ Integrated Care Systems (ICSs) across England, a long history of joint working across multiple organisations is often cited as a key reason for the progress they have made. Today, as other ICSs form without such a fortunate heritage, they will need to develop relationships, trust and mechanisms for joint working as swiftly as possible, in order to meet the practical requirements and expectations set out in the UK Government’s Health and Care White Paper.
As ICSs prepare to take on statutory form and responsibilities from next year, there will inevitably be a temptation for systems to ‘lift and shift’ their existing working arrangements into this new context – especially as ICSs must be designed and implemented alongside ‘business as usual’ requirements. However, this may present a missed opportunity for ICSs to work in fundamentally different and more integrated ways right from the start – something which individual leaders and organisations have long called for.
From our work with ICSs across the country, we see several changes system leaders can make to embed strong collective partnerships from the outset of ICS working - no matter what their past or present experiences of joint working might be.
Clear, shared vision and specific objectives
Leaders from across the system must work together to develop and communicate a vision and priorities which are specific to their system, and jointly articulate what specific benefits their ICS will bring – and how it will achieve them – over and above the wide range of work which they will already have underway. This is more difficult than it sounds. A generic ‘case for change’ might make clear that something needs to be done to integrate care, but not necessarily why the system’s specific ICS arrangements are the best way to do it. Likewise it could clarify which outcomes the system needs to improve, but not which service areas will be prioritised (and by implication, which de-prioritised) in order to improve them. It is this specificity which will make the difference as the ICS goes from designing change to delivering it on the ground.
Historically strained relationships can give rise to challenges when creating a clear, shared vision. Challenges may arise with engaging local authorities, who have their own priorities, not necessarily related to those of their NHS partners. However, if ICS leaders can bring local government and voluntary sector organisations into their discussions as active partners right from the start, this will ensure that the system’s vision and objectives are genuinely co-developed, and that the process of developing them takes differing organisational perspectives into account.
If leaders don’t yet have the relationships across the system to have such profound conversations, preliminary discussions can still be hugely valuable. For example, bringing NHS clinical leaders and council elected members together for an open discussion about their respective aims and objectives will, in our experience, reveal alignments – even in areas with a history of tensions and controversial decisions.
Solving problems together
With a shared vision and objectives in place, system leaders can begin turning them into reality. The White Paper and recently published Integrated Care System Design Framework provides some principles for partnership working and pointers on governance formalities, but the work of designing arrangements which support effective, practical local change is up to each individual system.
ICS governance and leadership arrangements should not be constructed as a piece of design separate from the service improvements they are trying to make for their populations. Rather, system leaders should identify integration programmes that will make a tangible difference to service provision, and therefore to patients and citizens, and work on them together. This will ensure that systemwide governance arrangements have something significant to govern right from the outset – something which is often missing when new governance arrangements are established.
This joint approach to problem-solving from systems leaders then needs to be replicated at the frontline. Empowering teams to work together on changing what they offer to the population they serve – taking an iterative and ‘citizen-centric’ approach – will deliver more creative changes more quickly than is possible through traditional ‘top-down’ service re-design. Small changes to how organisations work together can make a big difference. For example, physiotherapists working in a community setting can relieve demand on both GPs and specialist musculoskeletal services, as well as giving patients faster access to specialist care. Or GPs could bring voluntary sector services into their surgeries to identify and help patients at risk of social isolation, improving both health outcomes and wider wellbeing.
This approach allows ICSs to foster leadership at all levels – from the Board to the front line – and therefore to make a reality of system-focussed and place-based working which is more effective at breaking down organisational boundaries.
An ongoing process
Finally, it’s important to remember that building system leadership is a process rather than an event. Effective working relationships between leaders – and empowerment at the frontline – will not be built overnight. However, there are steps which leaders can start taking immediately to move in the right direction.
Continual progress in this area will be essential if ICSs are to truly work in a more integrated way for the populations they serve, rather than simply continuing existing practices within new structures.
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