While commissioners’ and providers’ views on success factors and barriers to system working were fairly unanimous, there were three areas where opinion was divided.

Changing legislation

Current legislation, with its emphasis on competition over collaboration, and its strict dividing line between commissioners and providers, was cited by some contributors as an insurmountable obstacle to real change. Those who saw the situation this way felt that the role of CCGs would be unlikely to change until there is new legislation "the expectation amongst everyone is that very soon, there will be a much smaller formal commissioner, but our CCGs are not acting any differently, and are clear that they won’t, until their statutory role has formally changed". The majority of those interviewed however held a different opinion, namely that the current legislative framework offers sufficient flexibility to facilitate meaningful change. One leader stated: "I keep saying: lean into the future and behave as though we’ve had new legislation and are one organisation."

Our CCGs are not acting any differently, and are clear that they won’t, until their statutory role has formally changed.

   Trust leader

I keep saying: lean into the future and behave as though we’ve had new legislation and are one organisation.

   CCG and ICS leader

What accounts for this difference in views? One explanation is that fear and uncertainty about the future – both for organisations and individuals – contributes to commissioners strictly upholding the traditional role of the CCG. In addition, areas with a history of collaboration and strong relationships seem less likely to encounter this issue, suggesting that here too, trust and strong relationships ease the path of change. Whichever view is taken, it is clear that CCGs and providers have to comply with the law as it stands.

 

The impact of previous failures

The second area of divided opinion was the impact of previous system failures. Across STPs and ICSs, there are areas facing deep-seated challenges with legacy issues around finance, quality and/or access. Ultimately as systems look to trail-blaze new commissioning arrangements, there is a risk of organisations 'getting their fingers burned'.

A couple of interviewees described how  a legacy of challenges has led to a break-down in trust and dialogue and an entrenchment of organisational "fortress mentalities". In this context, each statutory organisation looks after their own interests and bottom line, and a more integrated approach seems doomed: "We have a board with all the right people on, and everyone is supposedly neutral when in the room together; but in reality everyone is in it for themselves and pushing their own organisational agenda". In such cases, there was much time and effort spent on activities like contract disputes and delineating each organisation’s respective statutory duties.

Keep things safe and quiet now, to avoid unwanted national attention

   Trust leader


Providers in Cambridgeshire and Peterborough described a situation where, feeling badly burned, the system is reverting back to traditional, transactional contracting with a sense among both managers and clinicians to "keep things safe and quiet now, to avoid unwanted national attention". There is a worry that this effect may be long-lasting, even though there is a local belief that the principles behind the initiative were absolutely right: the sharing of budgets, and the bringing together or hospital and community teams. While there are small-scale integration work and pilots now under way, for example joint education sessions and ambulatory care, there is no appetite for large scale pilots or initiatives.

Several leaders, however, described the opposite - the challenges of their local systems meant that all organisations had come together in the realisation that they "were out of road, and had to do things very differently or go under". Another leader said: "Don’t waste a good crisis. It has made us braver and bolder…we’d rather take control of our own destiny than ‘be done to". It therefore seems as though deep-seated and system-wide challenges, whether concerning money, quality, access targets, or some combination thereof, can either make the transformation and integration journey that much harder, or it can serve as a perverse kind of enabler of that journey.

Don’t waste a good
crisis. It has made us braver and bolder...

   CCG leader

Similarly, in Hillingdon, an initial failure led to a more positive set of developments. The local system had initially wanted to establish a capitated budget for the integrated care partnership to manage and was in the process of designing the appropriate governance and financial structures. This task proved too ambitious and all parties considered the risk too big but instead of reverting back to old ways of working, the commissioner and providers identified system priorities and targeted more achievable changes.

Case study 4: Adopting a pragmatic approach in Hillingdon

Context: Hillingdon lies at the edge of the North West London STP. Providers, operating under an integrated alliance called Hillingdon Health and Care Partners, and the CCG have started to move towards a 'joint implementation' model in which the providers take responsibility for reorganising services, while the CCGs act as 'stewards', and manage resource transfers.

Progress: The providers and the CCG had initially looked to establish a capitated budget, along with appropriate governance structures. It was soon determined that setting up this structure would create a significant amount of risk and so the plans were abandoned. Nevertheless, there remained an appetite for collaboration between the CCG and providers. An alternative and more pragmatic approach was eventually adopted. This focused on individual pathways, with the CCG setting out ‘the challenge’ (including desired outcomes), and the providers developing a business model. The model was initially used for MSK services in Hillingdon and is now being applied to ophthalmology. It is underpinned by open and shared planning and regular challenge from both sides.

What determines whether a system reverts to a more traditional, risk-averse and siloed way of working, or takes another step forward and tries again? Again, the strength and history of local collaboration and the quality and longevity of relationships, as well as the tone set by local leaders, all factor in. Another factor appears to be the degree to which a local system, or local leaders, felt singled out and subjected to criticism by the centre or in the media. Not surprisingly, such an experience is likely to inhibit future risk appetite and possibly undermine existing relations.

 

The impact of policies and behaviours of national bodies

Contributors varied greatly in their views of the degree to which the centre (NHS England, NHS Improvement and other arm’s length bodies) were helpful in facilitating collaborative working. There was a shared view of the significant burden of what was felt to be excessive data requests and demands for information, sometimes at very short notice. Many also felt that the current assurance regime was excessive as well as poorly joined-up between system partners, and that regulatory frameworks were lagging behind developments on the ground.

People were split between those who felt that the permissive policy landscape, where many kinds of models and initiatives could be trialled, was a positive thing which encouraged local problem-solving, innovation and bespoke solutions, and those who believed that the lack of a central implementation plan meant that a huge amount of time, effort and public money was being spent "reinventing the wheel". One chief executive called for a roadmap from the centre to cut out duplication of effort and wasteful spend on legal costs. Others gave the advice: "Don’t wait for permission from the centre or for being given formal ICS status – just go ahead with the work and with the necessary change!"

 

Don’t wait for permission from the centre or for being given formal ICS status – just go ahead with the work and with the necessary change!

   CCG leader

Support and oversight

The majority of contributors felt that the burden of reporting to the centre was excessive, and some reported that it ate up so much resource that the job of making things happen locally suffered. Many said that NHS England and NHS Improvement was not as helpful as they could be and described demanding and inflexible management behaviours. One interviewee reported a deep fatigue with the centre and the national system, and especially commented on how the organisation felt "fed up with NHS England policy and changes and being told what to do".

Especially challenged health economies found the national bodies’ interventions counterproductive and an additional burden and hindrance rather than a help. One interviewee felt that: "They keep pulling up the plant to check its roots" and suggested that a more productive way forward would be for the centre to help the challenged health economy develop a three to five year programme of improvement

 

The keep pulling up the plant to check its roots.

   Trust leader

There were notable exceptions to this, with one leader describing a "very positive journey with the national NHS England team" comprised of constructive, tailored help and support. In particular, this local system felt that the national team were "rooting for them" and trying to bend rules and requirements so as to support local plans and initiatives, and that they had the confidence and trust of the centre to 'get on with it', without having to explain their every move. By contrast, at the regional level they found their local NHS England team rigid, inflexible and disinterested in offering constructive support, focusing on detailed assurance instead of the bigger picture.

 

Regulation

Many contributors noted that regulation tended to privilege the status quo over innovation, and was lagging behind actual developments on the ground, with current regulation focusing on individual statutory organisations rather than system working. This was felt to be a counter-productive way of working that caused frustration, delay and poor use of resource. One chief executive reported how some "very unhelpful regulatory behaviour damaged relationships and set us back several months". Some providers in more mature systems felt that NHS England behaved as a quasi-regulator which was not aligned to system working and there was a general criticism of ‘national ivory towers’ that are divorced from the realities of system working. Respondents were also critical of the mixed or inconsistent messages they have sometimes received from different national bodies. However, there was cautious optimism expressed about the national developments of bringing NHS England and NHS Improvement closer together.

Like national regulatory approaches, the current financial framework was seen as inhibiting collaboration by pulling CCGs and providers back into organisational silos. Both providers and commissioners would welcome a longer-term planning cycle to allow systems to focus more on outcomes-based planning. The existing units of measurements were felt to hamper taking a population-based approach.

A few contributors commented on how the rapidly shifting terminology and the centre’s changing ways of describing the ask of the system was confusing and often off-putting, especially for clinicians. One interviewee said: "We’re trying to ignore all that national noise and come up with our own story and our own plan that is de-coupled from all the national lingo."