The challenges facing integration pioneers

At the King’s Fund’s recent integrated care summit, one of the key policy challenges identified was the current contractual and commissioning arrangements for primary care and the importance of redesigning the existing model.

‘Local leaders will need to focus on what best meets the needs of their populations rather than their individual organisations’

Under the new arrangements, commissioning of primary care services is the responsibility of the local area teams of NHS England, not the local clinical commissioning groups. Some CCGs believe they need more direct involvement in the commissioning of these services if they really are going to make a difference and offer an enhanced level of service within a primary care setting.

At the summit various ideas were discussed − some CCGs suggested they use their pioneer application to take on the delegated responsibility for commissioning primary care services, within a framework agreed with their local area team. Others felt they could work closely with their local area teams and place contracts with a group of GP practices or, in some instances, use the flexibilities of the current personal medical service contracts. 

Removing barriers

Other challenges facing local NHS and social care organisations wishing to implement integrated care at scale and pace are a variety of technical issues, such as payment mechanisms, contracting, governance arrangements and regulation.

‘Integration of care in itself is not a technical or a policy challenge, it is much more of a leadership challenge’

Pioneer sites will have the opportunity to work with a range of national organisations, such as Monitor, to remove some of these technical barriers. For example, they may wish to explore payment systems that reward continuity of care across organisational settings rather than activity-driven contracts; this is something we have promoted as a potential development of payment systems in our paper on payment by results.

Others may wish to challenge the current rules on procurement and a range of other regulations that appear to support organisations rather than systems of care. 

However, although overcoming these challenges is important, from our work with a range of different localities across the country, we argue that integration of care in itself is not a technical or a policy challenge, it is much more of a leadership challenge. If pioneers are to successfully implement integrated care at scale and pace, we will need to see changes in behaviour and, in some instances, a significant shift in organisational culture.

Team working

Local leaders have an extremely important role in developing the vision for integrated care and demonstrating commitment to working together to improve services for a defined population, as explored in our paper, Making Integrated Care Happen at Scale and Pace.

Perhaps even more important, however, they must also model more collaborative behaviours to those delivering and managing services. In addition, they will also need to focus on what best meets the needs of their local populations rather than their individual organisations.

‘Ultimately, it is the actions of the staff working in and with the health and social care organisations that will make integrated care a reality

Different types of conversations and decisions will be needed by leaders to remove the disincentives for integrating care. Health and social care leaders in many areas such as Manchester, Bradford and Cornwall are now meeting and starting to engage. 

The implementation of more person-centred, coordinated care will also require greater teamwork among clinicians and managers – in many instances this will require a shift in both working patterns and mindsets to successfully work across different care settings.

In some localities, action learning sets have been formed to bring together professionals from different organisations, allowing people the space and time to work through issues together. In other instances, more formal leadership development programmes to equip clinicians and managers with the necessary collaborative skills and behaviours will also prove beneficial.

Systems and processes will need to change, but it is perhaps the shift in behaviours that is perhaps the most important. Ultimately, it is the actions of the staff working in and with the health and social care organisations that will make the goal of integrated care a reality. 

Nicola Walsh is assistant director, leadership, at the King’s Fund