The leadership style and skills required to drive and deliver system-wide change is different from what most current leaders have grown up with. NHS leaders are used to sitting on different sides of the commissioner/provider divide, with conversations traditionally based on negotiation. The changing commissioner/provider relationship will require a different sort of leadership and in light of this some contributors called for more national support for current and emerging system leaders.
Local systems are working to develop their own leaders. One contributor is looking to appoint a single joint accountable officer for both CCG and provider organisations. In Frimley a joint finance director already sits on the trust board but still holds an honorary contract with the local CCG arrangement. Others have taken a different approach to STP and ICS leadership development, such as the 100 system leaders’ scheme, a system-wide organisational development initiative in Lancashire and South Cumbria ICS, which brings clinicians and managers together on one leadership programme.
Leaders from some advanced systems described what they saw as critical aspects of leadership on a system basis:
- Developing a shared vision and agreeing priorities, and then taking people with you – doing so by changing mindsets rather than "telling people what to do".
- Facing disagreement and different points of views upfront and not shying away from difficult conversations. One leader noted: "We have lived through some really difficult conversations together, but without making it personal – and this has built trust. We trust each other, even if we don’t always agree."
- Trust was consistently identified as the key building block, with several contributors citing the dictum "our progress moves at the speed of trust".
In terms of how people had managed to build trust and develop collaborative working, some leaders highlighted that:
- There are no shortcuts: doing this kind of work takes time, and a lot of it. One leader said: "You have to put the time in. You need to open up about your own challenges and what’s hard for you… We all own the problem; and we all own the solutions."
- It can be very helpful to have honest conversations in facilitated spaces: external and objective facilitation can enable difficult things to be said and heard.
- Leaders should be clear and explicit about their commitment to and expectation that others will have the same commitment to:
- the shared task at hand
- building trust and relationships
- ensuring that organisational boundaries will not be a blocker.
- Including all system partners: a good starting point is to engage clinicians with a clear vision, keep patients involved throughout the journey and include social care from the start. These are critical building blocks – they should not be add-ons.
- Organisations also need conflict resolution mechanisms agreed upfront for the rare occasions that joint positions do not work out.
You have to put the time in. You need to open up about your own challenges and what’s hard for you.… We all own the problem; and we all own the solutions.CCG and ICS leader
There was broad consensus that clinical input and leadership are necessary to drive constructive local change, however contributors also acknowledged variation in the extent to which local systems had developed these key enablers of change. Some interviewees noted that clinical leadership hadn’t really been put front and centre of their local integration initiatives, but instead seemed an after-thought. Others reported the opposite – namely that the local vision had been co-designed with clinicians who as a consequence acted as project champions for the proposed changes.
A frequently expressed view was that people were concerned to maintain and not to dilute the centrality of clinical leadership introduced with the reforms of the 2012 Health and Social Care Act. Clinical engagement and leadership were believed to be central both for rethinking and redefining patient pathways, and for leading and promoting change with the public. As one interviewee noted: “Without clinical leadership, you have zero credibility.”
Relationships and engagement
When probing more deeply into the centrality of strong relationships and engagement in successful system working, some key findings emerged:
- Engagement with patients and the public must be valued. Several contributors noted that genuinely engaging with local people could engender unexpected and positive results, with fresh ideas and a willingness to entertain change. Leaders overwhelmingly recommended early engagement with patients and communities as a must-do part of any pathway redesign work and in the formulation of population-based outcomes for an area.
- Getting GPs 'on board' and drawing on their rich understanding of local need and proximity to local communities was seen as a critical step that needed to be taken early in the journey. As secondary care providers take on more of the planning and designing of place-based healthcare, they are well positioned to partner with primary care and support its delivery. A few areas described how either the local CCG or acute provider had helped GPs federate or form an alliance, in the belief that strong and cohesive general practice was the critical cornerstone to further development. Others related how their local acute trust was supporting general practice to address prescribing overspend and an over-reliance on high-cost drugs by sharing its own learning and expertise.
- The importance of close working relationships with the local authority was highlighted by many, while also recognising that the political aspects of a local authority can seem alien to NHS leaders. One thought leader noted that the NHS often learns from local government’s capacity for change, as most local authorities have a long-standing track record of significant organisational, social and economic changes. A couple of providers noted some tension with their local authority between their own pathway-centred approach, and the local authority’s place-based approach but also acknowledged that this need not be a negative tension as it could generate constructive learning on both sides.
Context: Luton CCG is part of the Bedfordshire, Luton and Milton Keynes (BLMK) Wave One ICS, currently operating as a shadow ICS. The three CCGs share a joint accountable officer and joint chief financial officer and are progressing well with recruitment to their newly-formed joint executive team.
Progress: In addition to working 'at scale', there is a clear focus in BLMK on transformation ‘at place’. In Luton, a key strength of local commissioning is the CCG’s strong relationship with the local authority. A milestone in this relationship was the signing of the Luton health and wellbeing concordat in June 2017. This statement of intent sets out the ambition to align strategic health and wellbeing commissioning functions through closer collaboration, integrated working and co-commissioning arrangements.
Pooled and aligned budgets are being used in commissioning services designed around the needs of Luton’s residents rather than adhering to traditional commissioning silos. The CCG and local authority co-designed and procured the integrated wellbeing service Total wellbeing Luton, bringing together social prescribing, healthy lifestyle services and improved access to psychological therapies (IAPT) into a single point of access. Service users are holistically assessed and provided with support to meet their varied needs, whether they require debt advice, social support, weight management services, talking therapy, or all of the above. Personalised health and care planning and, where appropriate, personalised health and care budgets, are another area where focus has changed and new ways of working through integrated teams has benefitted the local population.
Progress has been enabled by mature local relationships and hard-earned trust between people at all levels in the organisations. These have been built over time and have been aided by stable leadership and a shared vision, centred on the aspiration of improving the lives of Luton residents.
The CCG and local authority are scheduled to move into shared premises in December 2018. Although co-location is not essential for collaboration, sharing the same working environment should remove some of the more practical barriers to integrated working and help further strengthen relationships between CCG and local authority colleagues. This should facilitate closer working and is expected to be a key enabler in accelerating Luton's journey of place-based transformation.
If commissioners and providers are to undertake new functions and roles, they must have access to the skills and expertise to deliver them. Having a workforce with the right skills and capabilities, in addition to simply having enough people to safely deliver care, is a top priority and a growing challenge. Almost all contributors reported the difficulty of filling vacancies, and some referred to the specific impacts of Brexit, with additional worries about what the future might bring. New expertise is also sought – with clinical commissioners focusing on population health management, actuarial and modelling skills come to the fore, while providers may need different expertise and additional capacity in information analysis, sub-contract monitoring and supply chain management.
Almost all contributors reported difficulties in attracting staff with the required skills. A leader in a challenged area described the dawning realisation that there wasn’t enough money or staff in the local health economy. This meant that organisations increasingly pooled resources and functions to make best use of scarce capacity and to avoid duplication and waste. This included joined-up recruitment drives across the whole patch and deploying staff differently, for example staff with strong project management skills being placed at the heart of the system, independent of home organisations. Another example comes from Gloucestershire, where all staff in the CCG and approximately 160 staff in the local authority now have 'dual citizen' status, meaning they can work in either place and have access to the same electronic network.
Leaders within commissioner and provider organisations also spoke of working together on joint projects. This could also involve establishing joint HR, IT and other back office systems which save money for the overall health economy. Access to one electronic network was named a key enabler by several contributors who described co-locating local teams with access to the same IT systems so that people "stop seeing each other as different organisations and start seeing the patient."
The transfer of staff between CCGs and providers
Contributors recognised that providers may need additional capacity and new skills in-house if over time they are to take on additional activities currently undertaken by CCGs. Few systems were at the stage of planning for this, however there are some that have successfully transferred staff between commissioners and providers. In one example a CCG embedded some of its staff within the provider, with a memorandum of understanding and management agreement in place, however there remained difficulties in aligning organisational cultures. It is clear that embedding or transferring staff between organisations is a significant task and will require a lot of planning and engagement with staff, which will likely work better in areas with mature infrastructure and strong relationships.
Context: Since April 2017 Devon Partnership NHS Trust has been part of the new care models tertiary mental health services programme. The trust is the accountable provider leading a partnership of eight organisations across the South West to commission and provide adult medium and low secure mental health services. This is delivered across 22,000 square kilometers, covering a population of five million, within a budget of around £71m.
Progress: A formal delegated accountability structure is in place - all eight partners contribute to the clinical design, and are represented on a partnership board, alongside NHS England who retain statutory accountability for the commissioning of services. A five-year clinical model and business plan has been agreed through the partnership board, and a financial gain and risk share is in place across four of the eight partners. Some NHS England staff and functions are embedded within Devon Partnership NHS Trust, supported by a management agreement.
The partnership has been successful in reducing out of area placements, bringing around 85 people back into the South West region for treatment.
There was a clear interest in using the development of system working to create opportunities to review workforce planning, to develop new, attractive and flexible roles to recruit and retain talented individuals into the service, and to ensure that skills can be deployed across a wider footprint in the optimum way. Some contributors were keen to develop a new system wide culture in which staff felt comfortable with "working for a place rather than an organisation."
Some acknowledged the challenging nature of this ambition, citing the recognised need for people to belong to a specific group or team, and the importance of organisational affiliation. At the same time, it’s clear that there are developments underway in this direction. An ICS lead referenced everyone on the patch recognising the need to jointly resource the transformation work of the ICS. In this system an agreed HR framework enables staff to move between roles on the patch to where their skills are most needed, without a change in employment status. Similar arrangements are in place in other systems, allowing staff to take secondments across commissioner and provider organisations. Several acknowledged the challenging nature of this ambition, citing the recognised need for people to belong to a specific group or team, and the importance of organisational affiliation. At the same time, it’s clear that there are developments under way in this direction. An ICS lead referenced everyone on the patch recognising the need to jointly resource the transformation work of the ICS.
In this system an agreed HR framework enables staff to move between roles on the patch to where their skills are most needed, without a change in employment status. Similar arrangements are in place in other systems, allowing staff to take secondments across commissioner and provider organisations.
Others described an increasing number of joint appointments across the wider patch, as well as people working in 'virtual teams', for example, comprised of staff in community care, acute care and social care forming cross-organisational teams.
Some contributors were keen to develop a new system wide culture in which staff felt comfortable with "working for a place rather than an organisation."
Financial and contractual arrangements
Several contributors noted that new contractual forms have been the vehicle for formalising a local commitment to working differently together as commissioners and providers. In other systems, traditional procurement mechanisms, normally viewed as a pillar of the competition agenda, have driven provider collaboration and local health planning.
Many contributors pointed to the impact of current tariffs and payment systems, often felt to incentivise acute episodes of care, rather than focusing on outcomes along pathways of care. Some gave examples of how they have therefore tried to move away from tariff as a contractual unit of measurement.
A form of block contract was the most commonly reported contract model, with several contributors describing a block contract, with an agreed risk-share, in place for 2018/19. Several interviewees reported that this was working well, while one person felt this was a "retrograde step" that had resulted in more emergency demand in the system and "far more inappropriate referrals from GPs". One person described the risk-share arrangement as the hardest thing to agree on the patch, and another said that the whole integration effort is "primarily about managing risk, trying to situate the risk with the organisation/s most able to mitigate it, and giving them the power to do so". Both providers and commissioners noted that the volume utilisation risks under a block contract tend to sit entirely with providers. One leader commented that this could only be adequately mitigated by a built-in risk share underpinned by a detailed population health understanding and risk stratification. Some interviewees felt that their local system did not have the capability or knowledge to effectively manage risks and called for support on how to do this well.
The whole integration effort is “primarily about managing risk, trying to situate the risk with the organisation/s most able to mitigate it, and giving them the power to do so.CCG leader
One system leader described a close collaboration between the three acute trusts, the CCG, and the mental health provider on the patch, underpinned by a two-year block contract. The system had suspended the national tariff payments system and partners addressed their system control total by moving money between organisations to ensure the receipt of transformation funding.
Several interviewees described using a different kind of contract, such as an aligned incentives contract. In this approach, one set of priorities for the year was agreed between all parties, with an associated risk pool and a systematic programme of work across commissioners and providers agreed to avoid duplicating other improvement efforts (such as CIPs and the QIPP programme). This approach was felt to have led to much more sensible and constructive conversations and strengthened relationships locally, compared to the old style, non-value adding way of transactional contracting. One leader noted: "It’s the best way of getting skin in the game from all parties, using different forms of risk sharing". An acute leader described how approximately 75% of their contracts with commissioners were based on this type of contract, and how this had been very positive in terms of getting the right focus on outcomes and eschewing polarising and time-consuming contract meetings. This had also reduced the costs of the contracting teams and therefore saved money for the overall system.
Context: The national tariff arrangements between Bolton CCG and Bolton Foundation Trust were creating tensions, with continued disputes over counting, coding and payments. Both the CCG and provider agreed to find a more productive and collaborative way of working to manage system costs.
Progress: CCG and foundation trust executives agreed contracts and payments needed to be simpler. In place of the traditional national tariff payment system, Bolton designed a new aligned incentive contract which fundamentally shifts the focus from tariff prices to cost. This approach is based on six key principles:
• deficit of either trust or CCG is a failure of both
• collaborative working
• aligned incentives
• open, transparent conversations with no fear
• enabling and supporting the vision of the local system
• risks faced, shared and managed.
The contract has now been adopted by others and has won a Healthcare Financial Management Association award. The CCG and the trust believe that the new way of working removes barriers to transforming services and reducing costs, with both organisations working on joint projects under collaborative arrangements.
In some systems CCG procurement was seen as vital for provider collaboration, requiring providers to plan and design healthcare as part of a bidding process. In Dorset for example, the CCG put urgent and emergency care out to tender (including NHS 111 and advisory services, GP access and urgent care). As a result, several NHS providers entered a formal collaboration and drew up plans for the local system. This plan was submitted to the CCG as a bid and the provider consortium was successful in winning the contract.
In Hillingdon, a similar tendering process took place for musculoskeletal (MSK) services. The provider alliance partnered with its local Academic Health Science Network to assess the local population’s needs, review MSK service configurations elsewhere in the country and ultimately produce a credible plan for Hillingdon CCG.
In other situations, some noted procurement can be less of a facilitator to integration as it means that CCGs are inclined to put contracts out to tender when this is not always necessary, causing delays and undermining system working.
Establishing one version of the truth
The majority of contributors spoke about the importance of a shared source of information and intelligence to underpin collaborative efforts.
A shared vision
In line with the general focus on the importance of strong and trusting local relationships, several contributors mentioned the challenge of bringing about one shared vision, with an accompanying strategic plan and a roadmap for how to get there. One hospital-based leader outlined the key questions used in their system to guide both commissioners and providers:
1) What is the goal?
2) What care model do we need in our system, and what are the care interactions (including self-care and IT-based care)?
3) What does the system architecture need to look like to deliver the care model?
4) What functions are needed to do this?
5) What contractual arrangements lock together these components while remaining consistent with the regulatory and policy frameworks?
In line with the general focus on the importance of strong and trusting local relationships, several contributors mentioned the challenge of bringing about one shared vision, with an accompanying strategic plan and a roadmap for how to get there.
Open book accounting
Having one version of truth about the financial position was seen as a critical step towards being able to take on a system control total, and many contributors described an intention to move towards open book accounting between system partners. It is acknowledged, however, that this was a very difficult thing to affect, mainly due to “the ingrained culture of a competitive, siloed approach to contracting.” This is reflected in the perception of several interviewees who felt that all system partners in their patch still hold some information back.
It is clear that achieving complete openness about finances runs counter to the many years of competition and the culture of individual organisational responsibility in which most NHS managers have spent their working careers. Despite this, there were some areas, such as Berkshire, which reported having made the move to open book accounting, explaining that it worked well and solidified their system approach to driving change.
The absence of good and meaningful shared datasets in many local systems was noted as a strong impediment to change, with widely shared, reliable data, and the digital readiness to share that data appropriately, cited as key conditions both for establishing collaboration and effective planning based on trust. There were examples of a strong local commitment to achieving one version of the truth - Dorset, for instance, described what they called “360 degrees transparency” with regard to money, workforce and quality. A Local Authority Chief Executive likewise spoke about the importance of everyone "getting the same information, at the same time" and how this was becoming a reality in their place-based board.
It is clear that achieving complete openness about finances runs counter to the many years of competition and the culture of individual organisational responsibility in which most NHS managers have spent their working careers.
Governance and accountability
Systems have developed different governance mechanisms to underpin collaboration between organisations in the context of system working and to ensure clear lines of accountability to the public, regulators and national bodies. Ensuring robust governance arrangements to support system working and manage risk effectively was commonly seen as a challenge by local leaders, with some contributors highlighting a lack of national clarity and guidance on these issues.
Contributors emphasised the importance of building constructive and trusting working relationships between partner organisations, and developing a shared sense of purpose as the foundation for collaborative arrangements.
Accountability and challenge
In order to ensure clear lines of accountability in the context of system working, it is important to recognise the respective duties and responsibilities of CCGs and providers for the patient populations they serve. One CCG leader noted that a CCG is population based but, for the most part, a provider, serves a smaller footprint and delivers particular services within that population. This “subtle but important difference” should be considered when it comes to governance and public accountability. In the context of system working it is important to maintain clear lines of public accountability, and to be clear that even in the most advanced systems, within the current landscape, a distinction between the responsibilities of the component organisations within an ICS/STP, and between commissioners and providers, still exists.
Contributors also highlighted the importance of building lay and non-executive challenge into the development and assurance of system wide plans. This is difficult to deliver within the current legislative and governance frameworks, however some contributors had taken steps towards this end in developing reference groups involving CCG lay governing body representatives, patient representatives, trust non-executive directors and councillors in complement to CCGs’ and providers’ own processes for challenge and accountability. Contributors also emphasised the need to ensure that existing organisational structures (CCG governing bodies and trust boards) contributed to assuring system wide plans, given that the responsibility for decision-making still rests in individual organisations at the current time.
Some contributors reflected on where decision-making should best take place within the context of system working. For example, one trust chief executive suggested that around 80% of decisions should be made at place level - close to those both delivering and receiving services, and 20% should be taken at the wider system level (Kershaw, 2018).
The value of strong clinical involvement in decision-making processes was also recognised. Several places have established, or are establishing, a clinical reference group (CRG) to ensure this is built into the system from the start. The CRG is typically constituted by a wide range of clinicians and allied health professionals from primary care, community care, social care and acute care. Any decisions impacting on patient care or users of services, such as proposed pathway changes or redesigns, go to the CRG for agreement. In some instances, the CRG is constituted so that it can take on decisions formerly taken by the CCG, so that while the CCG is still formally and legally accountable, they are in practice simply ratifying the decision of the CRG. One leader described it as "locating decision-making as close as we can to the clinical coalface."
One leader described “locating decision-making as close as we can to the clinical coalface.”Trust leader
Finally, contributors recognised the need to manage conflicts of interest within the context of system working - and to ensure robust processes, including for conflict resolution between partners, were in place.