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.