To achieve better outcomes for people and place, ICSs need to change how they talk to patients about defining need and the ways in which those needs can be addressed, writes Michael Kitts
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The health white paper Integration and Innovation: working together to improve health and social care for all provides several references and commitments to greater consumer involvement and person-centricity, and a focus on:
- working together so that the people we care for can live healthier lives, for longer;
- rebalancing organisational duties to reflect the need for all health and care organisations to work collaboratively to deliver better outcomes for people;
- ‘continuing’ a culture of organisations working together in the best interest of not only their immediate service users and organisations, but also the wider ICS population and ‘place-based’ constituents;
- supporting the shift towards integrated systems which have strong engagement with their communities;
- driving ‘patient-centred’ approaches that provide greater choice and control to ‘patients’ by transforming services around the specific needs of their populations;
- overcoming the belief that health is ‘confusing, overly bureaucratic and does not support the integration and efficient arrangement of services in the best interest of patients’, and;
- Healthwatch England’s involvement, ensuring that all NHS mandates are informed by the needs of ‘patients’ and the public.
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There is a clear ambition to secure better outcomes for people and place by looking at things from the perspective of those receiving care – rather than primarily commissioners and providers. One example is provided by the International Consortium for Health Outcomes Measurement (ICHOM), which says that “Doctors think about prostate cancer in terms of PSA levels. The average patient doesn’t. That’s why we need to change how we evaluate and talk to patients about their health.”
The health and care sectors have significantly increased their focus on care recipients over recent years, but the White Paper calls for further progress. How can we go beyond organisational or structural change to make this ambition a sustainable reality?
The NHS White Paper describes the health and care systems as overly complex, with too much focus on the duties and responsibilities of individual care providers. This is exacerbated by discrete funding and incentivisation regimes, and a lack of genuine consumer involvement in defining need and the ways in which those with needs can be addressed. Recent analysis by IMPOWER identified that, in cases where we are aiming to keep people well and out of hospital, as much as 80% of the interventions required are non-health related. But how can these interventions be secured by NHS organisations with no more than a ‘duty’ to collaborate with local government, and an expectation of broader working with the Voluntary and Community Sector and other social determinant factors?
We must make this a sustainable reality
IMPOWER has a strong track record of enabling public sector organisations to grip the complexity of the systems they work in. We use strengths-based approaches that start with what really matters to care recipients, and focus on five key areas in order to secure real change and impact:
- Outcomes that genuinely matter – standing in the shoes of those who need enablement and support – what do they value, how is that best delivered, and how do we track, monitor and learn from their experiences?
- Consumer involvement – drawing on consumer and community knowledge and experience to drive innovation, design, improvement and a review of how wellbeing is secured. Evidence says that consumer experience, tracked longitudinally, is one of the strongest lead indicators – we need to go way beyond ‘consultation’.
- Culture and behaviour – the need to create equal value recognition across system partners, and to encourage collaboration, trust, positive risk taking and strengths-based approaches. Standing in the shoes of local people to deliver better outcomes for them – especially the frail, elderly or those with serious or multiple long-term conditions.
- Operating model – the need for support and guidance on the overall operating model and leading practice, whilst empowering local systems to innovate and create tailored and appropriate solutions.
- Workforce – the need to optimise the existing workforce, understanding the skills needed to support the blended suite of services or interventions that keep people well at home. Secure support and investment to develop skills and recognise that siloed working undermines genuine collaboration.
- Funding – the need for a joined up long-term funding and incentivisation solution (including benefits realisation) and single financial governance model.
Scotland’s health service runs a ‘What matters to you?’ initiative – this is the type of concept we need to look at and embrace. Simply reorganising things, changing the legal structures and making commitments will not shift the dial on securing better outcomes.
Appendix – HWP extract
White Paper: Integration and Innovation: working together to improve health and social care for all
4.2 For people using the NHS regularly, our proposals will support their GP and healthcare specialists to work together to arrange treatment and interventions that either prevent illness or prevent their conditions deteriorating into acute illness. This population health approach will be informed by better data and understanding of local populations, identifying those who are at risk and who we can impact, with a view to designing a more proactive way of planning and delivering care. It will mean that social care providers can receive emergency financial support when needed to prevent instability in care for the most vulnerable people in our communities. For staff working across the NHS, public health and social care, it should mean that there are fewer bureaucratic hurdles to overcome when they are just trying to do their job. It will support hospitals, GPs, local authorities and voluntary partners to work together to plan how they will address the health needs of their populations in the years ahead, including the use of technology, so that over time the people we care for can live healthier lives for longer. And it will ensure that the quality and safety of care continues to improve, through enhanced use of data, with investigations of things that go wrong so mistakes can be learned from.
5.14 Alongside the creation of statutory ICSs, we intend to introduce a new duty to promote collaboration across the healthcare, public health and social care system. Many existing duties on health and care organisations emphasise the role of the individual organisation and its own interests. We want to rebalance these duties to reflect the need for all health and care organisations to work collaboratively. When collaboration works well it leads to better outcomes for people, for example a successful early intervention can lead to people living independently and in their own homes for longer.
5.17 To further support integration, we propose to implement NHS England’s recommendation for a shared duty that requires NHS organisations that plan services across a system (ICSs) and nationally (NHS England), and NHS providers of care (NHS Trusts and FTs) to have regard to the ‘Triple Aim’ of better health and wellbeing for everyone, better quality of health services for all individuals, and sustainable use of NHS resources.
5.18 This will support NHS bodies to continue a culture of working together in the best interest of not only their immediate service users and organisations, but of the wider population, and for the ICS as a whole, working together strategically and through its ‘place-based’ constituents. We hope that the Triple Aim will help align NHS bodies around a common set of objectives, thus supporting the shift towards integrated systems which have strong engagement with their communities.
5.38 We will take forward the NHS’s recommended approach by retaining existing patient choice rights and protections and bolstering the process for AQP arrangements. In addition, ICSs can be powerful drivers of patient centred approaches that provide greater choice and control to patients by transforming services around the specific needs of their populations.
5.45 The NHS has sent us a clear message that the current regime for arranging healthcare services is not working. It is confusing, overly bureaucratic and does not support the integration and efficient arrangement of services in the best interest of patients.
5.78 This proposal will not impact on Parliament’s ability to scrutinise the mandate – each new mandate will continue to be laid in Parliament by the Secretary of State and will be published. NHS mandate requirements will also continue to be underpinned by negative resolution regulations, providing further opportunity for Parliament to engage with the content of the mandate. Furthermore, the existing duty for the Secretary of State to consult NHS England, Healthwatch England, and any other persons they consider appropriate before setting objectives in a mandate, will also remain in place. Healthwatch England’s involvement ensures that all NHS mandates are informed by the needs of patients and the public.
