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One year on: Building a truly Integrated Care System

Now is time to set the future for integration

Spring is upon us and with that opportunities for integration within the health and social care system. Indeed, this is essential, and the timing for integration could not be more critical. Over the past year, as Integrated Care System (ICS) leaders, you’ve come together from individual organisations to begin forming partnerships and you’ve worked together to develop strategies and operational plans for your system. Now, as you turn your focus on delivering these plans, it's time for you as leaders to set the future for the health and care system – to come together and use integration to address challenges – and create your legacy. With this, there is opportunity to create real, tangible change across all levels of the ICS. And to help you and your delivery teams accelerate this integration journey, we developed a simple and accessible toolkit for ICSs, ICBs and ICPs to ‘chunk up’ the change journey and design for truly integrated care.

Where to start

Across ICSs there is strong ambition when it comes to integrated care, but operational pressures persist and regulatory reporting requirements can side-track progress. And with this comes the question of where to start, what to prioritise and how to make the time. For some, the focus is about making a start through small incremental changes, but for others the integration journey can feel much further away and with that comes a focus first on getting all the requirements in place. For instance, the belief that all data infrastructure must be in place to deliver insight to design and implement PHM interventions. And yes, while that is important, we know there are ways to make progress now with the tools, relationships and capabilities you already have across your system and this toolkit can support you to draw these out.

Different, by design

Every ICS is different, by design. Tailoring care to the local population creates opportunities for differences that allow for tailoring across systems, places and neighbourhood levels. Questions arise around leadership. Are systems via ICBs leading the direction of travel for all, or should places and neighbourhoods start driving the change at a more local level? Other questions arise around configuration of services. Does it make sense to configure services around geographies, or specific demographic or disease cohorts? In short, as you start to put into motion your ICS strategies and plans, how do you make sure that you don’t set off on the wrong foot? We know each system will be starting from different places and approach this differently – and to support this, we’ve created a toolkit that will help you identify how integration could work in practice and what it means across each system level.

A toolkit to ‘chunk up’ the change

Our toolkit is designed to be simple and accessible for ICSs, ICBs, ICPs, place and neighbourhood teams to ‘chunk up the change’ journey. You can use our toolkit to first assess your level of integration maturity across the six core layers that reflect what we see comprising an effective integrated system operating model. You can use this assessment to then tailor and reflect the nuances of integration to create a joined up view of what is needed to build a truly integrated care system.

The six core layers explore the following:

  • Governance & Leadership: Who will lead and drive your integration journey?
  • Environment: What are your demographics and community assets and how are you leveraging them?
  • Relationships: How do your system levels & partners interact to deliver integrated care for citizens?
  • Outcomes: What outcomes does your ICS deliver for people?
  • Structure: How do you structure your ICS in an integrated way from governance structures through to digital and data structures?
  • Resources: How do you set up your resources (workforce, digital, estates) for success?

The toolkit can be scaled and used across each system level or across all levels at once to inform a joined up view.

Given the degree of change required, we know integration can’t happen across all six layers at once. And we also know from experience that by ‘chunking up’ the change across layers and themes, ICSs and their system partners will more easily be able to break down and prioritise what change needs to happen at each level, across each theme, and explore what that could look like.

Integrated System Success Stories

To bring this to life, we’ve drawn out examples of good practice and what we view as success stories – where systems are ‘chunking up‘ the change to build integration across the six core layers of the integrated system operating model – and demonstrating developing levels of integrated care maturity:

Integrated care is being set and delivered at place-level with autonomy given to neighbourhoods to tailor care to local need.

We often see with integrated care, the challenge of where does change occur first – is it driven from the top or is it bottom up, and if so who gives the mandate? This becomes tricky with multiple system levels and organisations waiting for that clear direction, which might not come from the ICB. We’ve seen systems where leadership is giving teams clear direction, they have a vision and are putting in place the tools and capabilities behind these team to encourage integration. This type of leadership knows their teams on the ground understand their population's needs and how best to organise services to support integration – these teams are trusted to make decisions, swiftly make positive changes, setting out examples of good governance across health and local authority (children and young people’s services being a good example). Whilst the ICS and ICB focusses on bringing together and developing the organisational structures and governance arrangements that will support place and neighbourhood teams going forward. 

System partners are joining up services and assets, targeted at needs across levels.

Systems with a strong understanding of Place and its features now and into the future are able to provide a direction of travel for the integrated care journey and help to distil real priorities which all partners can get behind. We have seen where shared knowledge of the needs of local people including how this may change over time; the assets which exist within and outside of formal service provision; and the unique place-shaping factors such as geography, demographics and economic drivers work to help systems to be better informed for the change afoot. Critically, this involves open dialogue with wider public services outside the health system. Places with devolved local authority powers are often well-positioned to support this on an ICB and regional footprint because they have a foundational understanding of place features and are leveraging new powers to enact change in line with this already. 

Relationships based on high trust and openness and are ‘swimming in the same direction’

With integrated care, the strength of local relationships and partnerships across health, local authority and VCSE are key. Across systems we are seeing an increasing focus on developing these relationships, where not already strong, and leveraging the already strong relationships to continue driving change to create increasing momentum, drive a positive direction of travel, which is bringing additional systems partners along on the journey. We’ve seen this accomplished across both health-led, local authority-led, and jointly-led initiatives, integrated neighbourhood teams being a good example – using the Fuller Stocktake as a way to build deeper relationships. There are real learnings to take from this, start where there is already a positive direction of travel, build on it and with those successes you will likely see other system partners that may have previously been resistant join in. 

All three levels are aligned on outcomes & KPIs across health and social care, and beyond

Systems which orientate the health and social care system around a set of agreed outcomes and relentlessly focus on this through the development and delivery of services that improve population health and deliver value for money. It does however require radical thinking about what good health outcomes look like, and how they should be delivered, recognising that outcome-focused ‘care’ models might ultimately rely on collaboration with wider public services such as housing and transport. Frailty models are a good example of this and have been rolled out in a number of systems. Falls are a key driver of poor outcomes, if the outcome is to reduce the number of falls, collaboration across housing, social care and primary care is needed at a local level to redesign and adapt interactions with those most at risk, driving a transformative way of working. 

There are common ways of working across the system which are recognisable to all

To achieve shared outcomes, it is imperative that the underlying structures are fit-for-purpose. Integrated care systems, if structured to incentivise collaboration, can achieve this. For example, there will be opportunities to process map and gradually align processes across Systems, place and neighbourhoods. There may also be opportunities to improve data sharing or align tech systems as these are replaced over the coming years. We have seen that, if done well, moving to Cloud-based systems or integrating electronic patient records using an aligned enterprise resource plan can align incentives, improve resource allocation, and ultimately free up frontline staff to focus on what matters. We have also seen value realisation through aligned reporting requirements, policies and terms & conditions. This all takes time and can be done in a gradual and prioritised way. 

‘One Workforce’ across the ICS

Building an open and collaborative culture is a key driver of any organisation’s success and despite leaders being aware of this, the requisite investment and time isn’t always afforded to building this culture. In our experience, if building a culture and intentional focus on addressing bad behaviours isn’t made a strategic priority, it can become a box-ticking exercise. Culture flows from the top. A first step for ICBs could be defining what kind of culture they want their leaders to drive across the system. Similarly, workforce continues to be a critical challenge across the health and social care system and strategic workforce planning is needed with integrated care to understand what the workforce is doing, what skills they have and at what cost, and how these will change over time. Our experience shows that strategic workforce planning is most successful when it is integrated within HR and more broadly across Finance, Strategy and Operations, and are responsive to in-year changes and evolving requirements. 

The toolkit is designed to help you - an ICS leader or a delivery team member - measure how much of your day-to-day work and approach has actually changed since the formalisation of ICSs, and to identify the strengths, assets and areas where further work is needed.

The toolkit isn’t prescriptive – it allows for each ICS to consider and plan for the ‘new normal’ in a way the suits your local economic, social and political reality.

And with recent key drivers such as the Hewitt review and the need for ICBs to reduce operating costs by 30%, it is timely that systems consider the totality of change required and how to go about this change as an integrated system.

Solutions will be imperfect, and that’s okay.The key thing is to get started.

Get in touch to hear more

In this short piece, we’ve introduced our toolkit. If this resonates with you, the challenges you are experiencing in your Integrated Care System (and at any system level) and are interested in discussing the toolkit and how you and your teams get started on building a truly integrated ICS.

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