The promise of a new ten-year plan for the NHS and the social care green paper, due in November, offers a natural moment to reflect on the value which collaboration in health and care systems can deliver for local populations. The pace of change in the NHS has been rapid since sustainability and transformation plans were introduced in 2015. In a few years, we have seen plans develop into partnerships and an aspiration that all STPs become integrated care systems (ICSs), taking collective responsibility for resource and performance management, and accelerating integrated care models.
STPs and ICSs vary in composition, population size and geography, and are all at different stages of development. However, this series of eleven interviews - including trust chairs and chief executives, leaders from commissioning and local government, national policy makers and thought leaders - provides a reassuring sense that common themes are emerging, both in terms of what drives success, and what enables improvement. In this overview, we summarise those common themes and look to what the future holds for collaborative working and integration.
Putting local populations at the heart of system working
A focus on outcomes, not structures
Given the different component organisations within an STP, it is apt that the local leaders we spoke to commonly described a shared focus on what all their system partners have in common – their populations, and in turn, the places in which they live.
Our contributors describe improvements in population health management and outcomes as the prime objective of collaborative working and integration. As Professor Sir Chris Ham, chief executive of The Kings Fund puts it: "The biggest potential gains are better outcomes and patient experience but also important are fewer handoffs and delays. Integrated care won’t reduce how much we spend on the NHS but it should enable resources to be used more effectively”.
Our contributors describe improvements in population health management and outcomes as the prime objective of collaborative working and integration.
This sentiment is echoed by Jagtar Singh, chair, Coventry and Warwickshire Partnership NHS Trust: "A move to place-based care should be about improving outcomes for patients. There are also opportunities to improve the practical support that partners offer each other, for instance improving clinician-to-clinician communications or exploring how a community and mental health trust can support an A&E under pressure."
Developing a sense of place
In Michael MacDonnell’s view: "Integrated care is not about structures, the wiring behind the scenes or even money flows. That’s why, although systems are important, the action is really in neighbourhoods and places. This is where the hard but exciting work is done to (re)connect clinical teams across traditional organisational and professional boundaries."
Most of our contributors similarly recognise that a sense of place is a catalyst for change on much smaller, more manageable, footprints than an STP or ICS footprint. Professor Sir Chris Ham reflected on this trend within the ICSs in particular: "Many of the most positive developments in ICSs are happening in neighbourhoods through the creation of integrated teams serving populations of between 30,000 and 50,000. Frimley is a good example and it has begun to bend the demand curve for hospital care by delivering more care in the community."
A preventative and multi-disciplinary approach
Michael MacDonnell’s vision for integrated care within systems is clear: "Chronic conditions…require continuity of care and joined up services that help people manage their own health. Preventing or managing these conditions requires services to get upstream… This is what integrated care means: the NHS and local government collaborating to provide joined up services that are ‘anticipatory’, with the aim of preventing ill health or unnecessary hospitalisation."
Most of our contributors similarly recognise that a sense of place is a catalyst for change on much smaller, more manageable, footprints than an STP or ICS footprint.
Both local and national system leaders emphasised primary care, social care and local authorities as key partners in this endeavour. For example, Samantha Jones describes: "Really interesting work [in Oldham] with…local authority leaders, taking accountability and responsibility for commissioning, with a strong focus on the wider determinants of health and working closely with a range of local providers including the voluntary sector".
In a similar way, Andy Burnham, mayor of Greater Manchester Combined Authority, identifies the role NHS organisations can play in partnership with other system partners to address the wider determinants of health: "Debt, poverty, housing, relationships and work are often the root causes of poor health in Greater Manchester… NHS organisations have a key role to play in supporting a more preventative, longer term approach to wellbeing and in paving the way for wider public service reform."
David Pearson, integrated care system lead for Nottingham and Nottinghamshire, corporate director, adult social care and health and deputy chief executive, Nottinghamshire County Council, was one of a number of contributors to emphasise the benefits of a multi disciplinary approach at the frontline: "When social care staff are working to a clear social care model and are properly integrated with the NHS, social care staff can influence the NHS model to promote different interventions. These staff then better understand the NHS model to refer people to services that can keep them independent and out of acute settings or a care home for as long as possible."
Several interviewees also acknowledged the cultural differences between different partners as a challenge to overcome. Karl Munslow-Ong, deputy chief executive, Chelsea and Westminster Hospital NHS Foundation Trust, brought to life the vibrancy of local political context and its impact on system working: "The politics associated with service change are often very hard to navigate, especially with boroughs', councillors' and officers’ accountability for delivering change across eight boroughs, with perceived winners and losers. We made some changes, and were stymied in other areas."
Both local and national system leaders emphasised primary care, social care and local authorities as key partners in this endeavour.
Making best use of collective resource and supporting the workforce
Given the financial pressures facing health and care, it is unsurprising that our contributors reflected on how system working could support systems to get maximum value from collective resources and to develop and retain a highly valued workforce. Overall there was a sense of the need for financial frameworks to better reflect the realities of system working, rather than to draw partners back into organisational silos.
As Alan Foster, chief executive,North Tees and Hartlepool NHS Foundation Trust, puts it: "The local system overall should benefit from initiatives to collaborate and integrate care, but the financial consequences may well sit in different places… So we have to find the right currency or compensate each other when change drives financial loss." Tim Goodson, chief officer, Dorset Clinical Commissioning Group (CCG), similarly highlights the need for trust between partners and a new cultural approach: "Getting surplus providers to consider the option of shared control totals is challenging; they’re financially prudent, and understandably nervous of losing any pooled money forever."
There were mixed views about whether more integrated models of care do generate savings however David Pearson importantly reflected on research to evaluate three different approaches to collaboration in Nottinghamshire: "Previous national policy was based on the idea that pooled budgets and integrated structures would make the difference. That proves not to be true: the integration model matters most."
Many of our contributors also highlight opportunities to better support, retain and develop the health and care workforce by developing multi-disciplinary working, new and more blended career paths, and deploying key skill-sets more smartly across an STP or ICS footprint. In his interview, Tim Goodson describes how enabling staff working in Dorset to move between organisations using the 'Dorset Passport' supports the development of a more flexible workforce and mutual support across organisational boundaries: "Our recruitment campaigns will start promoting working in the NHS in Dorset, as opposed to individual organisations. We recruit to the county, and then agree with staff where they will work. We hope this will allow for easier change in the workforce".
Many of our contributors also highlight opportunities to better support, retain and develop the health and care workforce by developing multi-disciplinary working, new and more blended career paths, and deploying key skill-sets more smartly across an STP or ICS footprint.
Navigating an uncertain and complex landscape
Diversity of approach
Given the diversity of population sizes and geographies covered by STPs and ICSs, it is understandable that the drivers for change, and the models being adopted, vary across the country – and this is reflected in the interviews from local system leaders. For example, Christine Outram, chair, The Christie NHS Foundation Trust, commented on Manchester’s devolution arrangements which “look and feel very different to elsewhere, with a much greater degree of system integration”. Sarah Dugan and Simon Trickett described their approach to use one trust as an ‘integrator’ or ‘host’ within the system which has had to invest in building new collaborative relationships and David Pearson describes two sub systems operating within his ICS.
While one of the benefits of system working to date has been the opportunity for local partners to shape a 'bottom up' approach to local issues, there remains a strong perception that the national bodies could communicate the desired 'end state' for STPs and ICSs more clearly. As our recent briefing on STPs set out, the diversity across the country raises questions about which models will improve outcomes and stay the course, and whether we do need a more unified approach.
Governance, risk and accountability
Several contributors highlighted the complexities arising from a legislative and regulatory framework set up to hold individual organisations, and not systems, to account. Professor Sir Chris Ham, sums the inherent tensions up concisely: "It is important to recognise that ICSs have no basis in law and are entirely dependent on the willingness of the organisations involved to work together. NHS trusts and CCGs have their own statutory duties and members of their boards may need reassurance that these duties are not being compromised by ICSs… Different accountabilities in the NHS and local government may also cause tension."
While one of the benefits of system working to date has been the opportunity for local partners to shape a 'bottom up' approach to local issues, there remains a strong perception that the national bodies could communicate the desired 'end state' for STPs and ICSs more clearly.
Some contributors acknowledged that progress is being made in flexing national frameworks. Sarah Dugan and Simon Trickett said: "It’s taken quite a brave move from NHS England and NHS Improvement to give us permission to use flexibilities to the maximum and back our system approach with flexibility on PbR and system wide performance targets."
However in general local system leaders were keen to encourage the national bodies to catch up to what STPs are doing locally, to enable partners to share risk and pool budgets where it makes sense to do so. Karl Munslow-Ong added: "National bodies still see and regulate us as sovereign organisations on performance, which unintentionally undermines working across boundaries."
Not all roads lead to the STP/ICS
The NHS has always operated on a number of different footprints with specialised and ambulance services covering more than one STP, and key requirements around quality of care and employment delivered at organisational levels. This has been a challenge for the Christie, whose chair Christine Outram, explains that this means “the ICS does not always provide the footprint we need”.
Leaders explained that successful systems need to look methodically at which services can be delivered at scale by the STP and which are best placed to be delivered as part of smaller local partnerships. As Sarah Dugan and Simon Trickett describe, working over large distances means they looked at how they could add value, and “what should be done at STP level and what made sense to deliver at locality level”.
What drives success?
Contributors identified the following factors which drive the success of those ICSs and STPs progressing well:
- strong system leadership and a culture of collaborative working
Strong relationships are almost universally described as one of the key drivers of a successful STP. In the absence of a legal basis for STPs and ICSs, any work to integrate across a system relies on the goodwill and buy-in of everyone involved, as well as tangible efforts to join forces in service delivery. Alan Foster noted: "One thing that really helped us in the North East and Cumbria was that we have a more stable set of organisations than in many other parts of the country. That meant that our leaders know each other. It’s a real benefit and enabled us to use those relationships to move things forward." Andy Burnham echoes this: "It is possible to have one conversation with all the players in the same room around health and social care: a chance to get a single vision shared by everyone and to start to pull in the same direction."
Contributors also commonly identified new skill sets required for collaborative working. Samantha Jones adds: "As a leader, you need humility to understand you don't have all the answers."
- a commitment to engaging widely, with the public, staff and clinicians
Sarah Dugan and Simon Trickett agreed: "The real strength of [their] STP is genuine engagement - including health partners, local councils, Healthwatch, voluntary organisations, and really strong primary care engagement." Whereas Jagtar Singh explains the importance of meaningful public engagement: “talking about accountable care Organisations (ACOs) and integrated care systems (ICS) is a big distraction for the public.” Instead, the focus must be on convincing the public of the benefits of working in collaboration.
- a shared understanding based on shared evidence:
Several contributors emphasised the importance of a shared evidence base and data sharing as a key enabler underpinning shared priorities and integrated services. Samantha Jones warns: "What continues to draw people back into organisational siloes tends to be a lack of clarity on purpose, and having no single source of truth".
Strong relationships are almost universally described as one of the key drivers of a successful STP. In the absence of a legal basis for STPs and ICSs, any work to integrate across a system relies on the goodwill and buy-in of everyone involved, as well as tangible efforts to join forces in service delivery.
What next for STPs?
Despite the variation in approach and perspectives across the country, it is encouraging that contributors commonly looked to patient outcomes as the benchmark they will use to determine how successful system working has been.
Michael Macdonnell makes clear that collaboration and integration will remain central to the forthcoming ten-year NHS plan: "The long-term plan for the NHS, which will be published in the autumn, will set out how we intend to catalyse [ICSs] across the country, supercharging their spread. These systems are the opportunity and the vehicle for providers to be at the forefront of evolving a health service fit for the next 70 years."
To achieve this we need to ensure that all local systems receive the support they need to progress, identify and manage risk in new ways and through new governance structures, and evaluate the diversity of models of care emerging to understand which offer the most benefit to local populations.