Using the building blocks of joined up care

If you are involved in the management, commissioning or provision of healthcare services, then integration, whether you are planning for it, working through the implications or looking to implement it, is likely to be high on your list of priorities.

But while there is evidence that integrating services leads to better outcomes for people - such as the European Observatory on Health Systems and Policies’ study What is the Evidence on the Economic Impacts of Integrated Care? - there are still major structural, cultural and financial barriers to integrating social care and health, as well as in bringing together primary and secondary care.

‘Most social care provision is obtained through the private and not for profit sector’

The financial incentives and funding mechanisms are different. Healthcare is free at the point of delivery, and costs for acute care are calculated on a tariff, or episode, basis. Social care is not free and for local authorities, it is effectively means tested.

Moreover, the number of people eligible for local authority care has reduced in the face of funding cuts - the National Audit Office estimated in March that 87 per cent of the adult population lived in local authority areas that only provided care services to those with substantial needs or higher.

So most social care provision is now obtained through the private and not for profit sectors. The links between these providers and NHS organisations are not always strong, and this contributes to inefficiencies in the system, such as delayed discharge or poor information flow, which can have a significant impact on patients’ experience of care.

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The leadership needed

These are the kinds of issues that a recent national initiative - backed by NHS England, Public Health England and Monitor - is using to address.

Systems leadership describes the kind of leadership used when seeking to lead across organisational boundaries. It describes the way to work when faced with large, complex, difficult and seemingly intractable problems; where multiple uncertainties need to be juggled; where no one person or organisation can find or organise the solution on their own; where everyone is grappling with how to make resources meet the demand which is outstripping them; and where the way forward therefore lies in involving as many people’s energies, ideas, talents and expertise as possible.

‘Systems leadership is useful when looking to integrate services and redesign them around the person’

It recognises that leadership is not vested in people simply because of their title or position; that it is possible - indeed, necessary - for leadership to be shared and ceded, and that you can come together on the basis of a shared ambition. It also requires you to accept partial or clumsy solutions on the way to getting there.

Systems leadership is therefore particularly useful when looking to integrate services and redesign them around the person, at a time when there is less money than needed and more expectations than can be coped with.

Alongside identifying a research base, a group of national organisations spanning the NHS, public health and social care have put in place a new initiative, called Systems Leadership - Local Vision, to try these approaches in practice.

Pioneering systems leadership

Systems Leadership - Local Vision is currently in place in 35 areas around the country, alongside working with health and social care pioneer sites.

The aim of these projects, each of which looks to create change in a difficult or “breakthrough” issue across a locality, is to develop systems leadership at a local level, to create new ways of working in support of delivering integrated services, and to achieve measurable improvements in health, care and wellbeing. In many of the projects, there has been real progress.

In Wiltshire, the health and social care sectors have come together to form a systems resilience group to integrate services and create a multiagency, 24/7 response for people with care needs. The group includes social care providers, healthcare and the local authority.

One outcome has been that home care providers are being better supported; this has been a direct result of health and social care seeing themselves as deeply connected.

They are also looking to form better relationships with the voluntary sector, and are currently exploring ways - including having three year contracts - to do this. Wiltshire has three demonstration sites around the county where the new service model is beginning to be rolled out.

‘Care is coordinated aroun the person through a single point of access’

Local authorities in Dorset, Bournemouth and Poole, through their Better Together programme, have similarly looked to bring services into a coherent local system.

It has started with senior leaders working together on a shared vision across health and social care, pooling budgets and working on a common strategy to redesign integrated services.

This has involved both service commissioning and service provision; the development of multidisciplinary locality teams (and therefore joining up training and development); joint resource planning; and shared delivery plans.

They are also seeking funding to develop an integrated social care record system for adult social care, and eight local agencies have come together to support a bid to set up a joint ICT service.

Single access point

In London borough of Merton, the Systems Leadership - Local Vision programme has led to a co-production process between health and social care, with good feedback loops between the front line, middle managers, clinicians and the senior leadership group, so people at operational level also feel they have responsibility for implementing the changes involved, and the leadership group can respond quickly when barriers come up. Strong links with users, carers and the voluntary sector, including Healthwatch, have also been created.

In Wakefield, west Yorkshire, Systems Leadership - Local Vision has supported development of an integrated model of care across the population, building on models already in place around mental health and learning disabilities.

‘Strong links with users, carers and the voluntary sector have been created’

This includes multiprofessional or multidisciplinary networks, linked to specialist hubs and based around GP practice populations. Seven GP led networks are being rolled out. They incorporate social care providers; social workers; occupational and other therapy services; community matrons; voluntary organisations; and community pharmacists.

The teams will be capable of delivering enhanced care, including intermediate care, out of hours care and more complex packages of home treatment. The initial focus is on caring for older people, people with long term conditions and people with palliative care needs at home, and enabling early discharge from hospital.

Care is coordinated around the person through a single point of access, a single assessment and a single care plan.

Relationships are crucial

Other projects have covered broader issues around long term health and wellbeing. In Cornwall and in Wirral, systems leadership programmes have looked at how to alleviate the rise in food poverty. In Plymouth, healthcare, public health, the council, the voluntary and third sectors, the police and the city’s university have been working together on reducing late night street drinking in order to benefit health and reduce demands on accident and emergency. In the London borough of Brent teams are working across health and social care to develop dementia friendly services.

Initial findings from the projects have been published in a recent report, The Revolution will be Improvised. Overall, although the projects have proceeded at different speeds, there are encouraging signs of real co-production and co-design with service users and carers, alongside better relationships between commissioners and providers, and between sectors.

So what are the lessons about what makes for success?

• Relationships and shared purpose are crucial - if you have these in place, you can weather the storms.
• Patients and service users - not organisations and services - must be at the centre. This is constantly claimed and rarely delivered, but when it happens, the results are transformational.
• Systems need to recognise that co-producing services with users is hard. It is a different way of working, and needs skills and strategy to make it happen.
• Leaders need to see themselves as part of the collective leadership of the system, as well as leaders in their own services and organisations.
• Collaborative skills are now essential to success. Organisations should make the ability to collaborate a key requirement for employment, development and promotion at every level.
• Public health can play a key role in driving integration forward.
• Key abilities include being able to operate in networks without clear rules, instinctively making connections, building shared values and trust, and building coalitions of support.
• Organisations and staff need to think and act strategically: the squeeze on resources makes long term thinking imperative. The greater the pressures, the more important strategic thinking becomes.

This is not to claim that the systems leadership is a panacea. But there is evidence emerging that it can make a difference in the way people behave, and therefore in the way that systems operate in the long term.

Debbie Sorkin is national director of systems leadership at the Leadership Centre. Email: debbie.sorkin@localleadership.gov.uk