Integrated care in england

© The King's Fund 2019
Operationalizing the OHT model –
perspectives and learning from
integrated care systems in England
Suzie Bailey – Director of Leadership and Organisational Development
Jo Vigor – Assistant Director, Leadership and Organisational Development
OHT Governance/Planning Committee 12th November 2019
1

Overview
• Brief introduction to the work of The King’s Fund
• Background to the development of Integrated Care Systems (ICS)
in the national health service (NHS) in England
• Perspectives and learning from England on delivering integrated
care models
• Q&A and discussion with executive leaders
2

Questions?
Making the shift from planning to operationalization
What are the tough decisions and lessons learned when you start
operationalizing the new model? How do you move from a pure planning
construct to an operational construct?
What are the mindset shifts required? How do decision making models shift?
How to be inclusive - and continually bring numerous stakeholders, including
primary care physicians, into the new model?
How do we build trust and manage through the ambiguity and volume of
change?
3

Who we are
The King’s Fund is an independent
charity working to improve health
and care in England. Our vision is that
the best possible care is available to all.
© The King’s Fund 2018
4

History
We were founded in 1897 by the Prince of Wales
– who later became King Edward VII – to help
London’s voluntary hospitals. Since then our work
has evolved in response to the creation of the
NHS and to changes in health policy and practice.
The funding built up in our early years helps us
maintain our much-valued independence.
5

What we do
Help to shape
policy through
research and
analysis
Develop
individuals,
teams and
organisations
Promote
understanding
of the health
and social care
system
Bring people
together to
learn, share
knowledge
and debate
6

Policy frame
• Strong articulation of the need for integration to
achieve population health by local leaders
• NHS Long Term Plan – January 2019
‘Local NHS organisations will increasingly focus on
population health – moving to Integrated Care Systems
everywhere’
‘We will continue to develop ICSs, building on the
progress the NHS has already made. By April 2021
ICSs will cover the whole country’
8

New Care Models
Vanguards (x50)
2015 - 2018
Sustainability &
transformation
partnerships
(STPs) (x42)
2016 – current
NHS focused
Integrated Care
Systems
(ICS) (x14)
2017 – current
Greater
collaboration
across health,
local councils and
other partners

Integration is now the agreed way forward in
England
• England’s population is 56m
• Covers a third of the population
• 2021?

© The King's Fund 2019© The King's Fund 2018
Background
• No legislative framework to mandate this way of working or
national blueprint
• Development has been locally led – no single ICS model
• Move away from siloed working and competition towards
collaboration and a focus on places, populations and
partnerships.
• Collaboration across organisational boundaries for better use of
the available resources
• Larger ICSs are working to improve health and care through
neighbourhoods and places as well as across whole systems,
emphasising the principle of subsidiarity.
11

Governance models in England are
still developing
12

ICS: Multiple levels of working
The NHS Long Term Plan set out the ambition to integrate health and care for
communities and patients.
This includes commitment for all systems to become ICSs by April 2021,
with strong partnerships between the NHS, local government and the voluntary
sector.
Activity is taking place at multiple levels:
• Neighbourhoods
• Places
• System
70 – 90 % of
focus at
neighbourhood
and place
10 – 30% at the
system level
13

Level Population size Purpose
Neighbourhood
c. 30,000 to
50,000
people
• Integrated multi-disciplinary teams
• Strengthen primary care through primary care networks
• Proactive role in population health and prevention
Place
c.250,000 to 500,000
people
• Typically borough/council level
• Integrate primary, community, local govt & hospital services
• Develop new provider models for ‘anticipatory’ care
Region
• Agree system objectives
• Hold systems to account for delivery of agreed outcome
measures
• Support system development
• Support improvement and, where required, provide intervention
System
c. 1 million to
2 million
people
• System strategy and planning
• Develop governance and accountability arrangements across
system
• Implement strategic change
• Manage performance and collective financial resources
• Identify and share best practice across the system, to reduce
unwarranted variations in care and outcomes
14

Two core roles of a system – system transformation
and management of system performance.
1. System partners work together to agree and deliver a co-ordinated programme of
transformational change, to improve patient outcomes and secure the long-term sustainability of the
system.
2. ICS partners in some systems are also coming together to collectively manage overall system
performance: ICS NHS partners together are collectively responsible for the overall NHS financial and
operational performance of the system.
Questions currently arising include:
• What is the role between the national performance and regulatory organisations, the system,
neighbourhood and place levels?
• The wide variation in size among the first cohort of ICSs means that they will not all be able to take on
‘system-level’ functions, and there is some discussion of how they may evolve to address this.
• This might involve the footprints changing, or neighbouring ICSs collaborating or even, in the longer term
merging.
15

Leadership and governance models for ICS in
England (2019)
• Effective leadership dependent on all system leaders working collaboratively, and a
dedicated leadership team able to lead the critical ICS functions on behalf of the
system.
• There are different models of ICS leadership in place in England with leads coming
from a range of organisations.
• There are different views on whether the ICS leader can or should be accountable for
overall system transformation and performance.
• Every ICS is required to appoint an Independent Chair and establish a Partnership
Board.
• The Chair leads the Partnership Board, promotes system-working and ensures that the
ICS develops and delivers its key strategic objectives through collaborative working.
• The Partnership Board will provide the key forum for engaging local partners, agreeing
system priorities and providing strategic steer.
16

Expectation of system level activities
• Agree a performance contract with the national regulators to deliver faster improvements
in care and shared performance goals.
• Manage funding for a defined population by taking on a ‘system control total’
• Create effective, collective decision-making and governance structures aligned with
accountabilities of constituent bodies
• Demonstrate how provider organisations would operate on a horizontally integrated
basis (for example, through hospitals working as a clinical network)
• Demonstrate how provider organisations would simultaneously operate as a vertically
integrated system linking hospitals with GP and community services
• Deploy rigorous and validated population health management capabilities to improve
prevention, manage avoidable demand and reduce unwarranted variations
• Establish clear mechanisms by which residents can exercise patient choice over where
they are treated
17

Financial and oversight frameworks
• An emerging picture – it’s a “wicked problem” for the NHS.
• National performance and systems regulators want to make sure that the NHS financial
framework supports system working and the delivery of more integrated care.
• All Integrated Care Systems (ICS) are developing a five-year system plan, which includes
financial recovery trajectories. This will form the basis of deficit support funding.
• Concept of ‘system control totals’ are being used to help organisations within an ICS area
to manage collective financial risks.
• Commissioners and providers are looking to establish a contracting and payment
approach that reflects a shared vision for services.
• The intent is that ICSs will play a greater role in oversight and assurance. Legislative
changes are needed and are a long way off.
18

Governance: Realities for local leaders
All the governance structures
and technical things in the
world are great, but if people
don’t have an aspirational
intent to work together, it
doesn’t really matter what you
write down. (Commissioner,
Frimley)
It does feel a bit like
walking through treacle if
you’re trying to get a
decision made quickly… I
find myself going around
in fairly significant circles
quite a lot of the time.
I think we still lack a real
sense of how we work
together...we just started by
scrambling for deadlines to hit
things, grabbing it from all bits
and pieces, grabbing people,
doing stuff, shoving it in…
(Acute provider, Bedfordshire,
Luton and Milton Keynes)
19

• NHSEI hold the ICS to account for the delivery of collective system performance
and agreed outcome measures.
• NHSEI continues to hold each statutory NHS organisation to account for
organisational performance, with the ICS leadership involved in discussion to some
extent.
Opportunities:
• Provides the ICS leadership some
opportunity to influence the oversight of
providers and CCGs (commissioners) in the
system
Risks:
• Maintains distinct reporting arrangements
for providers and CCGs, which may not
provide sufficient consideration to
collective system performance and not
incentivise aligned system planning
• Potential for duplication of discussions
between system and orgs
MH&C
TRUSTS
CCG(s)
ACUTE
TRUSTS
ICS
LEADERSHIP
NHSEI REGIONAL
TEAM
NB For illustrative purposes only, not official policy.
Leadership and accountability models (1/3)
20

© The King's Fund 2019NB For illustrative purposes only, not official policy.
• NHSEI hold the ICS to account for the delivery of collective system
performance and agreed outcome measures.
• The ICS holds each NHS organisation in the system to account for performance
and agreed outcome measures.
• This type of option may be dependent on legislative change.
21

© The King's Fund 2019NB For illustrative purposes only, not official policy.
• The leadership of all NHS organisations are collectively accountable to NHSEI,
and hold each other to account for performance and achievement of system
outcomes.
• The ICS lead acts as a convenor of this collective accountability model.
• This option would likely not be able to replace formal accountability between
NHSEI and orgs, and therefore may not require legislative change.
22

Accountability and governance – NHS England and
NHS Improvement maturity matrix
• Uses a progression model which shows a journey
• Recognises that systems will not develop all domains at the same pace
• Varying levels of maturity across each domain.
• By doing this, it seeks to support more nuanced and reflective discussions
about system maturity.
23

Against 5 domains:
• System leadership, partnerships and change capability
• System architecture, strong financial management and planning
• Integrated care models
• Track record of delivery
• Coherent and defined population model
ICS Maturity?ICS maturity matrix – June 2019aturity?
24

• Oversight
• Planning
• Finance – includes expected take-up of national improvement programmes
• Support – intense support for ‘emerging systems’ and expectation that all
ICSs will have a development programme
Intense support
ICS Maturity?ICS Freedoms and flexibilities – June 2019aturity?
25

Skills, authority and accountability
‘you can achieve almost anything so long as you don’t
want to take the credit for it’ and that ‘you have to give
away ownership’.
• Being able to walk in other people’s shoes
• Having a constancy of purpose while retaining
flexibility
• Building the evidence base for change as a key tool
for persuading the unconvinced
• A stable leadership team clearly helps
• Quality of relationships – whether with local
government, other parts of the local health system or
the independent sector – is crucial
26

System leadership in Integrated Care Systems
Leaders are
learning on the job
Trust develops
through repeated
interactions and
credible
commitments
Trust is undermined
when there is a
disconnect between
what leaders say
and what they do
Integrity, reliability
and fidelity are the
underpinnings –
and honesty
System leaders are
facilitative and
enabling, not pace
setting
27

‘Transforming systems is
ultimately about transforming
relationships among people who
shape those systems. Many
otherwise well-intentioned
change efforts fail because their
leaders are unable or unwilling
to embrace this simple truth.’
Senge et al 2015
28

Healthier Fleetwood – transforming the
relationship with primary care partners
Dr Mark Spencer – general
practitioner:
“Hope, a sense of purpose and
control over your own life and
your environment will bring
major health benefits for
individuals and the whole
community. This is health
creation.”
29

30
South Yorkshire and Bassetlaw – case study

South Yorkshire and Bassetlaw – case study
Sustainability and Transformation Partnership (January 2016)
Accountable Care System (April 2017)
Launched as a 1st wave ICS (October 2018)
ICS taking a lead on control totals
31

South Yorkshire and Bassetlaw – summer 2018
- There is a shared feeling we need to
move beyond positive strategic
conversations to real action and add
“grit” to the partnership
- We need a stronger plan & clearer
system metrics for all work streams.
- There are concerns we are not yet
adequately resourcing a number of work
streams, a context of financial constraint
and need to consider shifting dedicated
resource to work streams from other
priorities.
- Some partners raised the need to start
reshaping the system (and people and
investment) in line with our ambitions to
create a more prevention-orientated
system.
- The cultural and developmental
challenge is recognised by all partners as
a critical part of the agenda.
- There is further work to develop
ownership of the vision by frontline staff.
- The need to have a fundamentally
different commissioning approach was
raised by a number of partners.
- Workforce was raised by many partners
as a theme we need to make greater city
wide progress on.
- Alongside the strategic themes and aims,
how to make progress on some “knotty
system issues”– i.e. transitions, CHC,
Dementia, Older People’s care

SY and Bassetlaw continued
• Some partners discussed the need to build resilience in the city for community
wellbeing to support a cohesive approach to self-management.
• Some partners felt their confidence needed to be greater on the proposal of
the ACP that shifting resources to the preventative agenda would achieve the
reduction in secondary care demand anticipated.
• Some partners discussed the need to reshape how we work with the voluntary
sector strategically and operationally.
• There was a shared sense amongst partners that we need to raise the profile
for children and families in how we approach our system overall.
• Partners felt progress was being made with relationships and collaboration
across the city.

34

The real work… ‘You need to drink a lot of tea and
use a lot of shoe leather to build
the relationships, and those
conversations ebb and flow to get
you to a good position – to a
position where things happen’
‘It is constantly telling
the story. Painting the
vision of what it could
look like if we did it
differently. Being able
to pick up the phone to
people’
‘There is something about not
being ego driven and not wanting
to have your name splashed on
everything… Your success is
determined by everyone’s
success’
‘it tests the diplomat in you… It
is about persuading, and finding
consensus… It requires
sometimes being able to push
your own preference out of the
equation..’
35

Recommendations for local systems
- from a year of integrated care systems
• Invest in building collaborative relationships at all levels of the system
• Promote and value system leadership
• Integrate at different levels of the system, building up from places and neighbourhoods
• Draw on the skills and leadership of frontline staff
• Build governance in an evolutionary way to support delivery
• Develop system-wide capabilities to gather, share and act on public insights
• Develop active strategies to facilitate wider adoption of new care models
• Build robust evaluation into the ICS programme that supports learning and improvement
and measures progress
• Look beyond the health and care system to improve population health
36

Professor Don Berwick - reflections from
November 2019 visit
 Digital – no ICS really grasping the opportunity greater digitalisation can
offer to integration of health and care
 Too many metrics – measurement is not currently helping. Need to trust
narration – stories matter too! Make sure that the measurement is what you
really need.
 Social determinants of health – how to change the conditions where
people live?
 Mental health – priority and provision of care
 The role of compassion – the true integration of care and collaborative
leadership isn’t driven by targets – ‘it’s the relationships that will count’

Professor Don Berwick – continued reflections
 Release the intrinsic motivation in your people – get away from the need for
control
 Improvements in 100,000 population size is where you can release local
energy for change (don’t let the centre dictate how integration should look!)
 Don’t focus too much on getting the governance right – ‘learn your way to do
integration, derive the changes you need through the stories, not through
structures’
 Moving leadership behaviours from ‘what can I get’ to ‘what can I offer, how
can I help?’
 Break the rules a bit!

www.kingsfund.org.uk
Thank you/Q&A
39

Integrated care in england

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Integrated care in england

Similar to Integrated care in england (20)

Recently uploaded

Recently uploaded (20)

Integrated care in england