Based on a case study from within Nottingham and Nottinghamshire
As the English NHS and social care system responds to current need and challenges, national policy remains that integrated care systems provide the best way forward to improved population health, reduced inequalities and per capita costs.
Back in 2017 when Nottingham and Nottinghamshire was announced as an integrated care system (ICS) accelerator, with an early focus on Greater Nottingham and Rushcliffe, local leaders joined with Nottingham Business School in initiating a case study of the development. The predominant aim of the case study was to provide reflective insight and action learning to the local system.
This case study has drawn from workshops, roundtables, interviews, document reviews and analysis. Pre COVID-19, the over-arching finding centred on the NHS and social care system not being ready for comprehensive and systemic change, in the prevailing policy and operational environment. This finding was based on both local experience and national evidence since 2017.
On the whole, the lessons arising from the case study are not new, however, to date, they have not always been prominent, in the long history of system transformation and integrated care development in England.
The NHS and social care system is currently seeking to capitalise on the amazing innovation, new ways of working and collaborations encouraged by the coronavirus pandemic. However, financial and regulatory regimes are returning, and old behaviours are re-emerging. In this climate, we think that it is timely to share our learning more widely, with positive intent, to inform wider ICS success. In doing this, it is important to highlight that our own ICS journey continues to be a work in progress.
In the absence of a defined blueprint for such complex, special and challenging multi-organisational change, the lessons are presented in the form of 'Ten High Impact Actions for Integrated Care System Success'.
- Create common purpose: Create a compelling common purpose with and for your local population. Ensure this captures the ‘hearts and minds’ of everyone involved in health and care (in the widest possible sense) who instinctively and emotionally want to support population health improvement and the provision of high-quality care. Align everything and everybody to your common purpose and be clear that the only underpinning strategy is one of collaboration and integration – there is no alternative plan. This means delivery on the ‘triple integration’, between primary and specialist care; between physical and mental health services, and between health, social care and wider public and community services.
- Assess readiness: Getting partner organisations and their leaders ready to operate and behave as a high performing integrated care system is a major undertaking. While COVID-19 has required the NHS and social care to act as a system by default, going forward organisations are likely to be at different states of readiness to build on recent success. Assess readiness and risk appetite for change at appropriate points – this is not a one off or a tick box exercise. Build on areas where readiness is high and address areas where readiness is low.
- Tell the story: Get your system narrative, storytelling and communications strategy in place early. Have clarity about your audiences and your messages, being sure to manage perceptions and misconceptions, of which there are many about the integrated care policy agenda. Communicate your population health improvement and integrated care ambitions; provide the picture of the end state horizon even if some of the detail is still to be considered. Make it real, share practical examples demonstrating how short, medium and long-term goals are all being balanced and advanced as well as how ad hoc initiatives align.
- Embed and sustain the transformation endeavour: The beneficial changes in population health management and health and care delivery, achieved during COVID-19, must be embedded and sustained; further system transformation is also needed. However, there are known risks to embedding and sustaining such large scale systemic improvement, which have been well documented. From the outset, system leaders must recognise and work constantly to mitigate these risks, which include competing priorities divert attention, pump prime funding runs out, and leadership change stalls progress.
- Use data, measurement and evidence: Gain, and keep refreshing, detailed analysis of the value proposition of integrated care, in terms of improving population outcomes, quality of care, and reducing preventable activity, cost and unwarranted variation. Empower and enable clinical/professional leaders in relentlessly using population health data, measurement and evidence – with their teams – as the basis for targeted improvement and measuring progress. Population and system-wide insights and intelligence are a game changer; invest in the necessary analytical expertise and IT infrastructure to enable this.
- Adapt the lessons: Study the lessons on integrated care from both the past and the present day to improve your prospects for success – know what you’re taking on not least because, to date, nowhere in England has achieved the benefits now expected at scale from integrated care. The elements of high-performing integrated systems have been identified from well-known international examples – there’s no need to reinvent the wheel on this. However, they cannot simply be copied. They need to be tailored for the scale of the English challenge and each local context.
- Invest in capacity and capability: Do not underestimate the quality and quantity of resources needed to develop the experience and skills, and to foster the behaviours and values to enact deep-rooted system transformation. Invest in strategic and system leadership across all levels of the workforce together with improvement capability; nurture a culture of real-time learning for population health and system improvement. Ensure the frameworks and conditions are in place to enable staff to come together across organisations for development dialogues and to execute new pathways and models of integrated care.
- Focus on the physiology of change: In developing your integrated care system, focus on the physiology of system transformation. Understand the change process is evolving and non-linear. Become comfortable with emergence. ‘100-day milestone maps’ or similar are more valuable than detailed plans and Gantt charts; governance is more about managing uncertainty than checking solutions. Align clinical/professional energy and effort to achieving cycles of change and progress in pursuit of your common purpose. Celebrate success, keep taking stock and keep moving forward.
- Evolve your Incident Coordination Centre: During COVID-19, Incident Coordination Centres have enabled system oversight, coordination, resource allocation (including through ‘mutual aid’ endeavours), adherence to system-wide operating procedures and the escalation of risks and issues. As your system returns to ‘a new normal,’ evolve your Incident Coordination Centre into a day-to-day system-wide function which supports patient flow and operational management in an impartial, fair and transparent manner. Enable it to provide ‘one version of the truth’ in near time, informing an ongoing whole system approach to operational delivery; ensure the alignment of other important system functions such as your discharge to assess function.
- Tackle the barriers: The NHS and social care are not currently fully configured to accommodate the development of integrated care systems. Regulatory and structural impediments need to be constantly challenged, removed and worked around. Persistent and hard-to-solve problems need to be overcome. System leaders have responsibility for corralling all the key actors in determining and implementing agile solutions to the problems faced in a mutually supportive, collaborative and coordinated way. Coordination is paramount – you will only achieve a high performing system if all the individual parts are optimised and synchronised and therefore in tackling barriers in one part of the system caution is needed not to introduce unintended consequences in another part.
Research and leadership team
David Buchanan, Honorary Professor, Nottingham Business School
Simone Jordan, Visiting Fellow, Nottingham Business School
Rebecca Larder, Director of Transformation, Greater Nottingham/System Programme Director, Nottingham and Nottinghamshire Integrated Care School Visiting Fellow, Nottingham Business
Pete Murphy, Director of The Public Policy and Research Management Group/Head of Research, Nottingham Business School
Stephen Shortt, Clinical Chair, NHS Rushcliffe Clinical Commissioning Group /Clinical Chair, NHS Nottingham and Nottinghamshire Clinical Commissioning Group
Michael Hewitt, Nottingham Trent University Principal Lecturer