Meaningful Measures of Integration for Care

Dan Wellings writing at the King’s Fund: The NHS long-term plan confirmed, once again, that collaboration is now the organising principle of the NHS, and that integrated care is the idea on which national leaders have pinned their hopes. There have been a number of initiatives to integrate services over the past decade, but the pace picked up considerably with the appointment of Simon Stevens as the Chief Executive of NHS England in 2014 and the publication of the NHS five year forward view. If anything will define his legacy when he eventually steps down, it will be the success or otherwise of this.

Up to now, efforts to measure the success of integrated care have tended to focus on whether demand for acute services is reduced as a result of integration and whether costs for acute care are reduced. The evidence for these is inconclusive but focusing on these as the desired outcomes misses the point. NHS England says that for health, care and support to be ‘integrated’, it must be person-centred, co-ordinated and tailored to the needs and preferences of the individual, their carer and family. So, who is best placed to tell us whether integration is working? It is users themselves. What impact does integration have on users’ experience of services? Is their quality of life improved? The problem is we don’t have the right measures in place to answer these questions. This is a significant gap.

The health and social care system has an extensive survey programme, measuring people’s experiences of a range of services from the GP patient survey and the inpatient survey to the adult social care survey. The programme hears from over 1 million people a year, but while they measure experiences of individual services, they provide limited understanding of how well (or otherwise) these services are working together. Given we know that many of the problems people face are because services are not always joined up, we need to come up with new ways of measuring and collecting this type of data. If the system is transforming, then so should the ways we measure it.

This issue is recognised in the NHS long-term plan which outlines the need for a new ‘Integration index’, the aim of which is to ‘measure from patients’, carers’ and the public’s point of view, the extent to which the local health service and its partners are genuinely providing joined up, personalised and anticipatory care.’ It seems there is a real opportunity to put this right.

With this in mind, The King’s Fund, together with Kaleidoscope, held a workshop earlier this year bringing together a group of people to come up with potential solutions to this problem. It certainly felt like we had the right people in the room; representatives of national bodies, patient groups, academics, survey experts and people from local systems (both local government and NHS). As I was sending out invites, it became clear to me not only how many people were working on aspects of this question, but also how long people had been trying to come up with ways of doing this, myself included.

Several potential solutions were developed, tested, challenged and refined. There were a few ideas that might just work with the right backing and further testing. There will be pitfalls and barriers on the way; those of us who have worked on this agenda for some time are under no illusions about how challenging this will be to get right. The danger of this type of work is that it looks far easier at first glance than it is. To produce measures that are valid and reliable, allowing us to understand both variation across areas and between different patient groups, is no mean feat. There are lots of technical questions that need answering, including how to achieve the right sample – but the solutions developed in the workshop were promising, as was the consensus around them. There was a real optimism that this can be done with the right backing.

The participants were then asked to come up with reasons why the development of a new measure might not succeed, and the number one reason cited was that there would no ownership of the need to find a solution. It can be done, but it will not be easy and will need support from the very top of the NHS and local government to overcome the inevitable challenges. Too many efforts in the past have not had the necessary backing from those in the right places.

It needs to be done correctly, providing robust data that is fit for purpose. There is science behind these surveys in the way they are sampled, the way the data is analysed and how the results are interpreted. What is measured should start with what matters to people and it must be user led, but there should also be expertise in how the collection is designed.

Importantly, this work will require investment and time to understand the feasibility of the ideas developed in the workshop. There is a real risk here that something will be developed quickly that does not work. This is too important to get wrong. If done right it will be a significant achievement. If not, as Richard Taunt from Kaleidoscope said, we could be sitting in the same workshops in ten years’ time, still asking whether integration ‘works’ and still wondering why not enough has been done to put the right measures in place to find out.

‘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.