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Three questions about integrated care that should be asked in every NHS boardroom
John Copps outlines the key questions that providers should ask themselves in response to the Long Term Plan’s vision for integrated care.
It’s now four months since the publication of the Long Term Plan and, after the immediate blizzard of reaction, there’s been time for more careful reflection on what comes next.
A central axis of the Plan is its affirmation that integration is the end-goal for system reform. The Plan states that all of England will become part of an Integrated Care System, or ICS, by April 2021, with these growing out of current STPs. There’s nothing new or surprising about that – but the intentions are boldly expressed and the pace of change is rapid.
A consequence of the Plan is to issue a challenge to all NHS organisations. ‘What is my role in integrated care?’ is a question that should be echoing around NHS boardrooms. How organisations respond is likely to determine their future success or failure.
Three questions for NHS boards
I think there are three broad questions all NHS organisations should be asking themselves in response to the Plan. These questions provide the basis for a boardroom-level conversation about how to manage the opportunities and risks ahead.
1. Where do I fit in an integrated care system?
Successful organisations will be those that are crystal clear about where they fit into the system. For those with a clear answer to this, it is an exciting time. But those that don’t risk finding themselves hostage to circumstance.
In the commissioning world, we are already witnessing change. Each ICS, we are told by the Plan, will ‘typically involve’ one CCG. In anticipation of that, many CCGs are now talking openly about whether they will exist in a year or two’s time, and we are seeing increasing volumes of mergers and joint accountable officer appointments.
For providers, the prognosis is less straightforward. Integration implies working together, but also that someone needs to lead. This is where organisations that are already well-placed can seize their opportunity. In Greater Manchester’s ten localities, trailblazers for integration, joined up care is delivered with one ‘Local Care Organisation’ taking on responsibility for a population.
Another possibility is that more integrated commissioning triggers consolidation. Again in Greater Manchester, major reorganisation has included the creation of super-provider Manchester University NHS Foundation Trust through the merger of two acute trusts, and the establishment of the Northern Care Alliance under the leadership of Sir David Dalton.
Consolidation does not automatically imply smaller providers are under threat. Smart commissioning is still about what works and, as long as they are prepared, high performing smaller providers should have nothing to fear.
2. How do I become integration ready?
‘Integration ready’ means having systems, processes and people that can stand up to change. It goes almost without saying that robust financial management is more important than ever, information technology systems must be capable of harnessing data and sharing information in an efficient way, and estates must be able to accommodate new approaches that give patients more choice over where care is delivered.
Partnerships will also be critical. You need partners that you can rely on, with good relationships at every level. And this should not be limited to NHS organisations – local authorities will be increasingly important as the reliance on social care grows and care becomes more ‘place-based’.
Above all else, integration readiness is a cultural and workforce question. Do you have the skills and capacity to adapt to change? How resilient are your staff? The workforce will bear the brunt of change so need to see the rewards and feel that they can influence change.
3. What can I do to make integration sustainable?
Navigating the immediate changes are one thing, but making your solution stick is another. Governance is all-important here and organisations should have a careful eye on making sure their version of integration can survive future disagreements and changes in personnel. To imagine what this might look like, there are examples of integration take different forms – both contractual and structural.
Contractual forms of integration bind existing NHS organisations together under a legal agreement. To date these approaches seem to be the most popular, perhaps because they are easier to implement and allow organisations to retain their separate identities.
They include alliance agreements, where partners agree to collaborate under defined terms, whilst they may simultaneously hold separate contracts with commissioners. Alliances are established across the country, including in Cambridge and Peterborough, Wakefield, and Redbridge in East London. Evidence for their impact isn’t yet clear but it seems there is a spectrum from those that preserve the status quo to those that create genuinely joined-up services under single governance and management structures.
Lead provider arrangements describe where one provider holds the contract with the commissioner and sub-contracts parts of an integrated service to partners. This is becoming more common, for example in the arrangements in place across Greater Manchester’s ten localities. NHSE is working on an ‘Integrated Care Provider’ contract, which it hopes will become a template for good practice.
Structural forms of integration are more radical and involve changes to existing organisations or the creation of new organisational forms. They are more complex to establish but have the advantage of ‘locking in’ benefits, allowing the creation of a new culture, and removing the ‘friction’ between services provided by separate organisations. The Royal Wolverhampton NHS Trust’s model that combines acute and community services, and brings in GP surgeries across the city, provides an approach that has the potential to be replicated.
Which approach to integration organisations choose must be dictated by their circumstances, and what works locally. To balance sustainability and practicality a phased approach might be preferable – moving from looser contractual arrangements to a structural solution over time, to an end-point where multiple services come together under one roof.
Working out what integrated care means is the principle strategic challenge that the NHS faces over the coming years. As the 2021 deadline for establishing ICSs creeps up, the story will continue to unfold. Legislative change, the promised ‘further financial reforms’, and the much-delayed social care green paper will all need to be factored in along the way – but the basic questions will not go away. It is now up to the leadership of NHS organisations to shape the future.
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