The keys to achieving integrated care

Case study summary

At the 2019 NHS Confederation conference in June, a lively panel session considered the topic of ‘Achieving integrated care by 2021: how do we get there?’. The panel comprised four integrated care system leaders, and while the discussion touched on a wide variety of points, a few key themes shone through.

The importance of relationships

When Surrey Heartlands became an ICS, its first priorities focused around three main areas – citizen engagement, creating an academy, and linking with the local authority in a focus on the wider determinants of health.

Embedded in each of these is the importance of relationships, and Dr Claire Fuller, ICS Leader and Senior Responsible Officer, says that working more collaboratively has been crucial to their success.

“We’ve invested in the chief execs and clinical leaders across all the organisations, making sure we all get to know each other and understand the problems each organisation is facing”, explained Claire. “We’ve also worked on organisational development with our delivery teams, starting to enable that blurring of skill sets and helping people feel comfortable to take on roles that have traditionally been held by others.”

The ICS has also launched Surrey 500, a collective leadership programme for 500 managers from across the partnership and colleagues, as “the more time we can spend together, the better”.

There’s also been a focus on the relationship with local people. Claire added: “Our citizen’s panel is now up to 3,000 strong, and it is demographically recruited to by postcode, so we know that it is representative of the people, not just those who are shouting the loudest.”

Her advice? “Your boundaries will always be wrong; don’t worry about it, just work out who you need to have in the room for which conversation for which population and what sits where. And when you do make plans, make sure they matter to the people who live and work in the area.”

Getting the right systems in place

Adam Doyle, Chief Executive Officer at Sussex and East Surrey STP, also highlighted the importance of relationships and of governance in delivering success.

In 2016, the STP was rated the second worst in the country, and since then, he says success has been measured by finances. “I didn’t come to work to look at life through a financial lens, but when you are a deficit system to the level that we were, you have to,” he said. “This year, we are the most improved STP area in our financial framework, which has given us the ability to start to write a population health check.

“Why did the money get better? Because of the relationship that we managed to build with every single one of our counterpart provider chief executives.”

Adam added that consolidating governance processes such as the commissioning system across the eight CCGs also helped improve the STP’s position, with organisations bearing risk together – which he said “you can only do with someone that you trust.”

He also focused on the importance of creating an environment within and between ICSs where we can learn together, by stopping speaking badly of each other, by speaking positively when someone has done well, and by ending rivalrous behaviour.

Organisational development matters

The need for working in harmony was also picked up by Julia Ross, of Bristol, North Somerset and South Gloucestershire STP. The STP covers a population of one million people and is a complex landscape with 13 statutory organisations involved across a patch that includes three local authorities.

“Organisational development clearly matters,” she said. “It’s about getting people to a place where you understand where each other is coming from; where you stop pointing fingers or thinking ‘if you just gave me all the responsibility I could sort it out’.

“We’ve worked really hard on saying ‘can we have a shared view about what our challenges are, and then a shared sense of ownership about needing to resolve them?’”

Focusing on a shared destination

According to Julia, clinically-driven change is critical, as is a real focus on value-based healthcare.

However, she warns that ICSs may not be able to make changes at the speed or scale that they wish if they want to keep their clinicians and populations on board. In addition, relations will continue to be challenged by everyday problems such as meeting the four-hour target, so it’s key for everyone to keep their focus on the shared destination – and keep the faith.

Rob Webster, Chief Executive/Lead at South West Yorkshire Partnership NHS Foundation Trust and West Yorkshire and Harrogate ICS, also works in an area that is complicated by the involvement of a high number of organisations and interests from different sectors. He says “communicating effectively all the time is critical”.

An important first step they took as an ICS was to change the mindset – “You’re not stuck in traffic; you are traffic”. They realised that thinking about the issues they had wasn’t going to drive things forward; they needed to come together as a system with a burning ambition for everyone to get behind. Theirs includes their whole patch being healthy and giving everyone the best start in life, support throughout life, and the ability to die in their chosen place at the end of life.

Aligning strategy and governance

Rob adds that for good governance and relationships the local authority must be an equal partner on the ICS board and everything should be fair, open and transparent. For example, they have a joint committee of CCGs that meets in public and can make decisions, as well as joint committees for their acute hospitals and mental health providers, all of which are decision-making.

Rob concluded that ICSs need to constantly work hard to hold the partnerships together, saying: “All of this is incredibly hard. If you think competition is difficult, try collaborating!”

Watch the highlights from the panel here.