The Integrated care system (ICS) design framework sets out eight digital areas that integrated care boards are expected to deliver on from 2022, which includes "enabling a cross system approach to transformation, so that changes to models of care and service design involve digital and data experts working with partners from all relevant sectors".
In short, the ambition is for data and digital to drive system transformation. The reality, however, is that it is quite challenging to "do digital" at system level. There are varying levels of digital maturity between health and social care providers within an ICS. This makes it difficult to allocate funding; do ICSs invest more in helping those that are less digitally mature to catch up, or place their bets on those who are equipped to scale and share innovations? And that's before even considering the interoperability challenge. For trust boards, the agenda can seem quite daunting.
As part of a Digital Boards peer learning "member spotlight" event organised by NHS Providers, Katherine Church, chief digital officer at Surrey Heartlands Health and Care Partnership Integrated Care System (Surrey Heartlands ICS), and Kate Walker, digital director at Suffolk and North East Essex Integrated Care ICS, share their key learnings.
The first thing to say is that delivering digital at system level is not fundamentally different from good digital delivery more generally: you need a clear mission that everyone understands, with a relevant focus on user needs and a continuous investment in skilled, multidisciplinary teams.
But of course, it goes without saying that navigating the complexities of digital across an ICS presents new challenges. In our experience, this is how you can address some of these:
The system should be patient-centred
- Don't accept fragmentation. When designing services, it is inevitable that teams from different organisations will look at the same patient through different lenses. It is therefore important to step back, look left and right to understand the other things that may be going on in a person's life, and how our services collectively fit into this.
Consider the scenario in which a person with comorbidities may be trying to manage multiple symptoms and vital signs across a variety of different apps and through a mixture of phone calls and text messages. This patient's digital engagement with the NHS has not been designed with the whole patient experience in mind. So, while the development of individual services may seem patient centric, they can fail as a collective.
In Surrey Heartlands ICS, we take a 'citizen centred' approach which looks at digital interactions and devices across the whole system. Recently, this involved carrying out user research into our electronic referrals. We found that 25-30% of all calls into primary care were chasing appointments. Anecdotally, we heard that patients were not going on holiday for fear of missing a call back. The reality was that patients understood certain delays during the pandemic, but just wanted certainty. The ICS stepped in to inform them when they could expect to hear back about their appointment – a relatively simple fix that put the user's mind at ease.
In a complex, daisy-chain process where different services play different parts, we must build in clear sight of the patient experience into everything we do.
- Don't engage users. Involve them. To truly understand the digital needs of your patients and service users, you can't simply ask what they want. Convening patient panels isn't enough and will leave you with an incomplete picture of user needs. There is a key distinction between asking for feedback on digital services and involving users in the outset in design.
At Suffolk and North East Essex ICS, we worked with Healthwatch Suffolk and Healthwatch Essex to learn what gaps were present in our digital response to COVID-19. As a result, we published co-produced guiding principles to inform our digital initiatives. Only through applying these principles did we find out why and where many of our citizens struggled with the move to digital services, leaving them feeling isolated and disengaged from support. We wouldn't have picked this up through a patient panel; we had to involve these users in conversations about our digital services to get to this granularity. This challenged our assumptions and meant we could design services to meet real user need.
- Galvanise around anchor institutions. Strictly speaking, the constituent organisations within the ICS are your anchor institutions, and it is the role of the ICS to empower and join dots. For example, supporting the resilience of the voluntary sector is important, because you will gain valuable insight into how to transform lives for patients. 98% of wellbeing services are not delivered by the NHS.
For ICSs, this will also mean building patient centrism into internal processes and governance. In Surrey Heartlands ICS, we have updated our Digital protection impact assessment to include digital inclusion as a criterion. We now have a baked in assurance process that requires us to demonstrate how those with lower digital literacy have been considered and that our digital offering is just one option within an ecosystem of other non-digital channels.
Considerations for financing within a complex system
- Raise the profile of system-level priorities within trust boardrooms. Given the multiple demands for trusts' limited funds, it is often difficult to prioritise initiatives that would have the greatest system impacts when there are pressing trust needs that may take precedence. This might be because system-level investment in areas such as connectivity and interoperability often require longer-term investment and see a longer timescale for benefit realisation. When prioritisation exercises are conducted with a broader system-focused view, valuable opportunities to pursue system-wide benefits can be harnessed. Look towards your neighbours as you will likely see commonalities and therefore opportunities to collaborate.
- Fund your strengths. There are a range of strengths across organisations within a system, which ICSs can capitalise on through effective coordination. Organisation leaders should come together to identify the capability of each organisation and take on the responsibility to lead on their strength across the system. This approach gives organisations, no matter how small, the encouragement to lead and innovate in what they do best and allows the system partners to capitalise on the experiences and competencies of their peers.
In time, this may involve working towards shared assets and shared services. There is no reason to think that in the future an ICS couldn't have a single IT help desk, for example. But for now, this is about recognising who is the best at doing certain things, and enabling them to accelerate this.
Think beyond the boundaries of your own organisation
- Get the right people in the room to make decisions. All ICSs will be faced with the difficulties of balancing varying viewpoints, drivers and levers. From the onset it is important to have a clarity of focus: what benefits the system will ultimately be in the interest of each organisation and most importantly will be best for your patient populations. But all partners need to be given an equal voice at the table, including the voluntary sector, local government and other partners. Trust boards are tasked with managing the complexities of doing what is right for their organisation as well as for the wider system. This means taking into account system ambitions and maximising their alignment with organisational priorities. At Suffolk and North East Essex ICS, we make sure to sit on the different digital boards within each constituent organisation to understand what is going on locally.
- Be brave and share resources across your ICS. During the height of the COVID-19 pandemic, as reliance on technology to deliver care became more crucial, Surrey Heartlands ICS worked together with two community providers to level up technology across the system. In a COVID-driven acquisition, the ICS was able to purchase laptops, desktops, monitors and headphones to improve digital capability of our community partners. When you consider that a citizen's experience with the NHS is only one portion of their wider health and care journey, it becomes clear that sharing resources across a system, whether it be knowledge, data, or in this case, equipment, can help better serve the patient and their needs. And it is a practical way of building trust between different organisations. At Suffolk and North East Essex meanwhile, our digital leadership function is jointly funded by three different organisations.
Where to start
Digital success within an ICS will depend on leaders' abilities to break down organisational boundaries, collaborate effectively and maintain focus on health outcomes and the patient journey. Based on our experience, we would recommend trust board leaders consider the following:
- Identify the things you currently do well and accelerate these across the system – don't try to boil the ocean
- Give the workforce space and time to grow and learn about digital opportunities elsewhere in the system
- Put in a common data sharing agreement to speed up collective decision making.
The NHS Providers Digital Boards programme held the "member spotlight" series event Delivering digital at system level in October 2021. During this online event, a panel of ICS leaders discussed the challenges and opportunities of digital transformation across a system. The event was chaired by Victoria Betton, director at PeopleDotCom and featured panellists Katherine Church, chief digital officer for Surrey Heartlands ICS and Surrey County Council, Toby Avery, chief digital and information officer at Surrey and Borders Partnership NHS Foundation Trust, Kate Walker, digital programme director at Suffolk and North East Essex Integrated Care System and Mike Meers, director of digital and logistics at East Suffolk and North Essex NHS Foundation Trust. You can watch a recording of the event below.