‘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.

Using technology to build a partnership of trust with patients

Professor Sir Chris Ham writing at The King’s Fund: Recently I spent a day visiting the Haughton Thornley Medical Centres in Tameside, Greater Manchester, at the invitation of Amir Hannan, one of the partners in the practice. I’ve been aware of Amir’s work in engaging patients for some time and it was featured in our 2015 report on innovations in care. I jumped at his invitation and was fascinated by what I saw.

Amir showed me how patients access their own health records and gain a better understanding of their health care needs. Access and understanding are enabled by the use of apps that provide full online access to the GP electronic health record alongside the practice-based web portal. Patients are also able to book appointments, order repeat prescriptions and send two-way secure messages online.

Innovation in Care

Two-thirds of the 12,500 people registered with the practice have signed up (after an individual consenting process) for the online service and all the patients I met were aware of the service and were using it. This is a much higher coverage than in the rest of general practice, where the most recent GP patient survey shows awareness of online services offered by GP practices is still relatively low with use of these services considerably lower. The last survey showed only 3.3 per cent of respondents were accessing their medical records online.

Access to records and understanding are the foundations on which Amir, his partners and other colleagues have sought to build a partnership of trust with patients and staff. They are doing so in a practice that was formerly run by Harold Shipman, who achieved notoriety when he was convicted of murdering some of his patients between the 1970s and the 1990s. The commitment to responsible sharing and partnership has helped restore confidence in the care that is provided, and the practice was recently rated outstanding by the Care Quality Commission.

I saw how this works by sitting in on Amir’s morning clinic with his patients. The philosophy I observed was of patients being enabled to take more control of their health and wellbeing, for example, by checking test results, identifying and flagging any errors or omissions, and tracking trends in their care. Later in the day, I tested my observations in a roundtable discussion chaired by Ingrid Brindle who leads the practice’s patient participation group.

One of the benefits for patients is that they can share their records when they come into contact with other services and with family and carers. The latter is valuable for patients who are not confident in using online access themselves. There are particular benefits for patients with long-term conditions who are able to monitor their conditions and use information on their records to adjust their choices.

Reflecting on what I saw and heard, I was reminded of a phrase I heard many years ago on a visit to Kaiser Permanente in California, US. One of its medical leaders, David Sobell, told me that the most important primary care providers are patients themselves; the decisions patients take every day have a bigger impact on their health and care than those made by GPs, nurses and other clinicians. Systems like Kaiser Permanente had been slow to recognise this and Sobell was leading work to promote greater self-care by patients.

The NHS has also been slow to turn the rhetoric of patient engagement and patient empowerment into practice. The experience of Amir Hannan, Ingrid Brindle and their colleagues shows that progress is possible where there is a sustained commitment to develop a partnership of trust with patients. To be sure, the Haughton Thornley Medical Centres have more to do to get all clinicians, patients and the wider health and social care system involved, but their work demonstrates what can be achieved even within the limitations of existing systems and workload pressures.

What I saw was an example of the kind of NHS we need in the future, based on different relationships between patients and clinicians. These relationships have to be seen as meetings of equals in which the expertise of patients is at least as important as the expertise of clinicians and managers. They must acknowledge the responsibilities of patients as well as their rights and the vital contribution of patients in using information and understanding to improve their own health and wellbeing.

Technology can support this transformation, but fundamentally it is about a new deal with the public appropriate for the 21st century. As Derek Wanless warned in 2002, the public must be fully engaged in their care, otherwise the NHS will become unsustainable. The accumulation of many more locally led innovations, such as the one I observed, offers one promising way of heeding his warning and putting patients at the heart of care. I was left puzzled as to why all practices aren’t yet working in this way.