Quality in the design of integrated care systems

Dr Amar Shah profile picture

11 October 2021

Dr Amar Shah
Consultant Forensic Psychiatrist and Chief Quality Officer
East London NHS Foundation Trust


What can we, as board members, do to support the adoption of best practice quality improvement approaches in the way we design place-based and integrated care systems (ICSs)? This was a key question during a recent webinar on systems and improvement, part of NHS Providers' trust-wide improvement board development programme, supported by the Health Foundation.

In my view, quality needs to be more visible in discussions at every level of the system, just as it has become core to the way that improvement-minded healthcare providers operate day-to-day. We have an enormous asset to draw on here, as there is an increasing amount of quality expertise within our healthcare system. In the last five years, there has been considerable application of best practice improvement approaches within the NHS, led by a growing network of improvement experts. Much of this still lies within healthcare providers, where most of the quality improvement work has taken place. We need to invite these experts in quality and systems thinking to help us collectively design our ICSs so that quality is right at the heart of the way that an ICS is designed and led.

An improvement-minded leader is visible where the work is happening, where the value is added, directly connecting and supporting the teams that are improving care.

Dr Amar Shah    Consultant Forensic Psychiatrist and Chief Quality Officer

As board members, we can also help by shifting the focus from structures to relationships and on how we want to work, not how we want to provide assurance. With change of this scale, there is a risk of preoccupation with trying to come up with the perfect governance structure, probably because this gives us a (false) sense of control over the system if we see how information and assurance flows. This is, however, a fundamental misunderstanding of how complex systems behave. Leadership behaviours that support continuous quality improvement don't rely on a governance structure to escalate information for visibility on what is happening. An improvement-minded leader is visible where the work is happening, where the value is added, directly connecting and supporting the teams that are improving care.

When I've looked at system development plans for example, there's often been little or no mention of quality.

Dr Amar Shah    Consultant Forensic Psychiatrist and Chief Quality Officer

Therefore, we need to pay more attention in the development of ICSs to our ways of working. When I've looked at system development plans for example, there's often been little or no mention of quality, and that is a major gap. We often have finance, clinical leadership and workforce plans but relatively little about quality. If it is present, it feels disconnected from the rest and describes outdated views of quality management in healthcare – a missed opportunity to create a holistic management system for integrated delivery of outcomes.

Boards can also advocate for quality expertise to guide us in this. Quality management expertise is a specific skill that needs to be brought to this conversation at system level. Boards should advocate for such expertise to input into the design of their ICSs to ensure quality isn't limited to quality projects but is central to how we develop and deliver through ICSs. Best practice tells us that we need to build a culture of quality improvement that sits within a management system that clearly links quality planning to improvement, quality control and quality assurance.

Every ICS will already possess considerable assets to help us apply best practice quality thinking towards the triple aim of improved health outcomes, improved quality of care and improved value.

Dr Amar Shah    Consultant Forensic Psychiatrist and Chief Quality Officer

Every ICS will already possess considerable assets to help us apply best practice quality thinking towards the triple aim of improved health outcomes, improved quality of care and improved value. For example, commissioning bodies have excellent experience in planning and assurance; healthcare providers will contain people with experience of improvement and assurance. There is also no doubt a wealth of experience to be drawn from our various partners at place and system level.

The risk of not involving quality experts in the system design is that we will end up overly balanced towards quality assurance, as this is likely to be the dominant experience within those who have been working within commissioning structures, or those who are asked to hold the quality portfolio without the necessary experience and credentials. The establishment of ICSs offers us greater opportunities to collaborate and tackle issues that cross organisational boundaries. Bringing people together around a systematic way of managing quality that helps us navigate complex decisions together could help make this a reality and provide the opportunity to make it central to the design of ICSs going forward.

About the author

Dr Amar Shah profile picture

Dr Amar Shah
Consultant Forensic Psychiatrist and Chief Quality Officer

Dr Amar Shah is consultant forensic psychiatrist and chief quality officer at East London NHS Foundation Trust (ELFT). He leads at executive and board level at ELFT on quality, performance, strategy, planning and business intelligence. Amar has led the approach to quality at ELFT for the past 10 years, and has embedded a large-scale quality improvement infrastructure and quality management system, with demonstrable results across key areas of organisational performance.

He is the national improvement lead for mental health at the Royal College of Psychiatrists, leading a number of large-scale improvement collaboratives on the topics of suicide prevention, restrictive practice and sexual safety. Amar is also chair of the quality improvement faculty at the Royal College of Psychiatrists, and an improvement advisor and faculty member for the Institute for Healthcare Improvement. He is also an honorary visiting professor at City University (London) and the University of Leicester.

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