‘Moving at the speed of trust’ – the journey to integrated care systems

Anna Charles writing at the King’s Fund: In May of this year, NHS England announced four new integrated care systems (ICSs) to join the ten existing systems. But ‘announced’ is not really the right word; as we have found in our work with the systems, creating an ICS is most definitely a journey and not an event. 

We’ve been tracking these journeys over the past year, conducting interviews with more than 70 NHS and local government leaders and other stakeholders in eight of the first ICSs. Our new report, published today, sets out the findings from this work and identifies emerging lessons for local systems and national policy-makers.

Integrated Care

ICSs (and the new care models that came before them) have been introduced in a very different way to the NHS reforms of the past. Instead of central bodies passing legislation that enforces a uniform organisational model across the country, ICSs are being designed and implemented by local areas, within a broadly permissive national programme that emphasises peer learning and support. In the words of one local leader:
The honest discussions about the wicked issues and how they can best be navigated has felt, to me, like a breath of fresh air…You can’t just impose a blueprint from Skipton House or Whitehall. This has to be more iterative and co-produced.

There are some drawbacks to this approach in terms of the clarity and consistency of the changes taking place, but our work suggests that an ICS can only be developed in each place, by each place; they must evolve and be owned locally if they are to succeed.

Why is this? After all, we found strong similarities in the governance arrangements that the different systems are developing and in the service changes that they are putting in place. ICSs have much in common, and there is much they can learn from each other. But the strongest message that came through loud and clear from our interviews was that this had to be founded on collaborative relationships and trust between partner organisations and their leaders:

It’s relationships, relationships, relationships…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.

The systems have used a variety of strategies to address this, including bringing leaders and staff from different organisations together to spend time face to face, working through collective challenges, and creating a shared purpose. Building relationships cannot be rushed or centrally imposed; it takes time and commitment and can only be done locally.

We can’t do any of this quickly. This is very big change for a lot of people across the system. I think that to do it any quicker we would have just fallen over.

Individuals spoke candidly about how developing an understanding of other organisations’ priorities and challenges had altered their own perspectives and behaviours. They described greater openness and transparency across different organisations and new ways of collectively managing finances and performance as a result:

I’ve learnt more about how local authorities work in the past 18 months than I’ve done in the past 42 years…it’s been spending time with one another and understanding one another’s problems and issues.

It is still early days for ICSs. Local leaders need to continue the work they have begun by giving priority to strengthening relationships and trust, redoubling their efforts to involve key partners, and focusing on delivering further changes in service models to improve heath and care for their populations. They also need to take active steps to listen to and work with members of their local communities on an ongoing basis, ensuring they design services that meet their needs and reflect their priorities.

National leaders must hold their nerve in allowing ICSs to be built from the bottom up, while also offering guidance and support and doing their upmost to remove the barriers that ICSs encounter.

To end on the words of one ICS leader:

The ICSs will move at the speed of trust…this is really about relationships and trust between the partners.

Hate Crime on The Rise in Time of Political & Social Extremism

Most recent figures from the Home Office* showed a 29% increase in hate crime in England and Wales and these figures have consistently grown. We are going through a time of extremism, politically and socially on both domestic and international fronts and as a result hate crime attacks are sadly on the increase.

In the UK the Brexit issue has led to increased attacks on non-British people and the recent antisemitism row in Labour emboldens people to feel empowered to attack Jewish groups. The current US president seems to thrive on being combative and aggressive, #Metoo has created greater awareness and inequalities in wealth and power have grown. Leading psychotherapist Noel McDermott believes that when people feel they are excluded they look for scapegoats and more crimes like this are committed.

Hate Crime

What is a Hate Crime?

Hate crimes are linked in the UK to the 9 equality strands – age, disability, gender, race and ethnicity, religion and belief, marriage and civil partnership, pregnancy and maternity, sexual orientation and gender reassignment. If a crime happens and there is evidence that this happened because of one of these issues e.g. an assault happens on a male homosexual couple, it would not just be an assault but a hate crime.

Psychotherapist Noel McDermott comments: “Sadly these equality strands are groups of people in society who are institutionally targeted and seen as being “less than” by hate crime perpetrators – they are regarded as “the other” rather than “us” – with the white heterosexual able-bodied male seen as the template for the most privileged individual”.

Why do people commit hate crimes?

Unsurprisingly we know there are high risk groups of people who commit crime such as those who feel marginalised in some way (often economic or cultural marginalisation) or those who feel socially isolated. For these perpetrators we must look at what is happening to the human being inside to understand them. A loving connection is missing and often these individuals have trauma issues and will need specialist treatment to help to deal with this or they will become more isolated or dangerous.

We have only to look at gang crime and the crime-ridden estates in London. These young people have been brutalised and groomed some even from as young as 9 years old, their initiation rites will involve shooting a stranger or assaulting a friend as part of the recruitment procedure. Often these kids will have high levels of trauma and will have flashbacks to their own abuse whilst committing their crimes. Untreated PTSD creates aggression, and this is a huge factor in violence and the rise in hate crimes.

Traits of a hate crimes perpetrator

  • Previous exposure to and involvement in violence is the biggest single predictor of current risk of perpetrating violence
  • Poverty or extreme wealth where people may exist in closed sub groups can lead to extreme views of the other not being challenged
  • Isolation from the mainstream
  • Anger management issues

Generally, people who are likely to go on to commit a hate crime will be vocal about their prejudicial views and be prone to creating an image of themselves as somehow victimised by the groups they hate.

Noel is as a great advocate of awareness weeks such as National Hate Crime Awareness Week (13th-20th October). He believes it is essential that we have public education. The damage of a hate crime to the individual who is targeted is huge and impacts on our society and these public education campaigns challenge this behaviour.  He says: “This week highlights the issues to the public to get the conversation going, the more open we are about these issues the better. Additionally, they will encourage victims to come forward. The campaigns can focus on issues of current concern and combat misinformation with fact”.

What to do if you are a victim of a hate crime

As with any crime it should be reported it to the police. With hate crime there is increased monitoring so it’s helpful to report small things such as verbal abuse in public. If it’s abuse about one of the protected characteristics, it is considered a hate crime. Additionally, the victim may want to seek specialist counselling for the experience. In general, this type of crime exists within the context of larger issues of discrimination that will have been faced by the victim in their lifetime and as such they may have an ‘aggravated’ response. It is possible that victims will have experienced this kind of discrimination before and a hate crime can be very damaging for the individual’s mental health.

Be aware that if after two weeks the victim experiences things such as intrusive thoughts about the incident, a general sense of wariness, a tendency to be jumpy, being short tempered, emotionally labile, trouble with sleep, changes in diet and habit, avoidance of activities or things that remind them of the event, then they are showing signs of anxiety and will need help to overcome this. Long term stress can kill and in some cases victims can suffer extreme reactions such as self-harming and a fear of leaving the house, this needs to be taken very seriously.

Noel McDermott is a pioneering health and social care professional with over 25 years of industry experience. He is passionate about bringing high quality care and support to those who are vulnerable. Noel’s areas of expertise include social care, mental health, child care, refugees, trauma, addiction and recovery, distance therapy, personal development and emotional health and wellbeing.