Integrating care and support: tango or tangle?
The integration dance
This article was prompted by a stimulating session on integrated care systems (ICSs) led by Chris Naylor from the King's Fund for members of the Think Local Act Personal (TLAP) team and National Co-production Group (NCAG). But first, a little Strictly Come Dancing for you.
Students of dance, which I am not, will tell you that the tango originated in South America around the 1890s. As it took off and spread to Europe it was seen by many in accepted society as a step too far; much too daring. Significantly, in the context of integration, (and this is where you really do need to know your dance stuff - thanks Wiki) the tango is a form of partner dance whose basic choreography involves the coordinated dancing of two partners holding each other close, as opposed to dancing alone or in a non-coordinated way. I have been wondering whether this might be a metaphor for our current quest for integration. If it works, the prize will be organisations working together in lockstep to provide great joined up health and care with and for people - if it doesn’t, everyone will end up in an unholy tangle.
Clear vision in plain sight
In terms of weighing up the tango or tangle prospects let’s start by looking at the how integration is now being framed. One of the main aims of the Health and Social Care Act 2022 is to shift the health system away from a competitive internal market approach which is thought not to have succeeded in bringing about the level of improvement in outcomes, quality and choice originally expected. This verdict was reinforced by the response to the Covid-19 pandemic where collaboration at pace has led to significant innovation and breaking down of organisational silos and boundaries. We now have a policy, structure and set of rules explicitly designed to promote collaboration across health and care in which the role of ICSs is central, with their purposes of improving health outcomes, reducing inequalities, and for the NHS to contribute to broader economic and social goals in ways which improve value for money and productivity.
ICSs have a wide brief. They are about promoting wellbeing as well as good health and contributing to reducing inequalities and broader economic and social goals....
There is much to get behind in this ambition. But there are also some unanswered questions, not least the place for social care, how ICSs will improve wellbeing as well as health, and what the reforms mean for key policies like prevention and personalisation at a time when there is strong public concern over access to primary and acute health care. The risk of tangle seems to warrant at least an amber RAG rating, but there are opportunities to ‘do this right’.
Firstly, what are the risks? For those of us who are working with but not inside the NHS the purpose and vision for ICSs feels quite NHS-centric, as if the NHS is extending its hand of partnership to social care and others. As one NCAG colleague remarked, it is as if the NHS is at the centre of the constellation surrounded by orbiting satellites. The purposes set for ICSs do not include any explicit recognition of the role that good social care plays in enabling people to lead meaningful, connected and contributing lives that help build individual and community wellbeing. ICSs cover large populations with structures that are hard to fathom, even for those working in the system. For example, how the ICB Board and ICS Partnership are meant to work together and the distribution of decision making between the ‘system, place and neighbourhood’ look complex even on paper, but much more so now, as the heavy lifting is underway to take the words off the page. Despite the best of intentions there is a risk of muddle and confusion with a lack of clarity on who is taking the key decisions. One NCAG member describes his local arrangements as “impenetrable.” The same colleague went on to describe how a valued easily accessible psychiatry service has ended with the advent of the ICS, but his GP did not know why. The stakes are sizeable and risk leaving the public befuddled, or worse, positively hostile. They are even higher for the millions of citizens of all ages with long term conditions, who need health and social care to work well together so we move closer to the standard in TLAP’s Making it Real that ‘I have care and support that is coordinated and everyone works well together and with me’. We know from the many people we work with and our partners at TLAP that people are often their own integrators through necessity, faced with a fragmented and disjointed system which leaves them filling in the cracks. All too often this burden falls on family carers.
It is often said that timing is all. Like the introduction of the Care Act, which coincided with austerity beginning to bite local authorities, the timing of the new system is less than ideal. The policy intentions in the Health and Care Act 2022,and preceding Care Act, are for health and social care to provide more early help and prevention and create services that are more personalised, which enable people to exercise choice and control over their support to reflect their whole lives, rather than reliance on siloed and narrow interventions.
The current climate is tough, but there is a need to retain a focus on prevention and personalisation...
This remains the correct ambition but we are now bumping up against the rock and the hard place of people struggling to access primary and urgent acute care and requirement on systems to bring down waiting lists for elective surgery. From what we see at TLAP we believe that ICS leaders remain committed to dealing with these current demands, whilst not giving up on transformation and the ambition to forge closer and more co-productive relationships with the people and communities they serve. Important as it is to improve the flows in and out of hospital, the support that people require ‘before and after’ must be front and centre. Unless we seriously invest in early help and prevention in combination with truly personalised care and support, the risk is that we fix the symptoms and not the causes and other areas don’t get the attention they need. For example, too many people with learning disability and autism are still spending too long in assessment and treatment units, in large part because of a failure of practice and commissioning to build support around the needs of individuals and families.
The support that people require ‘before and after’ must be front and centre, otherwise we risk fixing the symptoms and not the causes. Social care has a vital role to play here....
The government’s decision to review ICSs, led by the Right Honourable Patricia Hewitt, provides a window of opportunity to reinforce the direction for ICSs, so that dealing with the immediate pressures does not freeze the transformation for a health and wellbeing system for which there is a broad measure of consensus.
How then can we make this happen? Our experience suggests transformational change is more likely if ICSs move forward with a clear, easy to understand vision and purpose which lays out the direction of change, is strategic but relatable to people’s lives. We should not prescribe what this looks like, as this would clearly be too top down, but we would expect it to give at least equal emphasis to health and wellbeing, and define the contribution of social care which extends beyond describing it as an adjunct to the NHS. At TLAP we think Making it Real (MIR) is a useful framework, elements of which are in CQC’s Single Assessment Framework, and could provide a strong basis for systems, places and neighbourhoods to coalesce around, including areas that support Social Care Future’s vision which speaks to people’s lives across and beyond care and health boundaries:
“We all want to live in the place we call home with the people and things that we love, in communities where we look out for one another, doing things that matter to us.”
Agreement on vision and purpose should also serve to protect against imbalances of power and resources within the system which risk being skewed to NHS priorities-often the acute sector. Achieving this in practice requires engagement and co-production with people and communities. These in turn need investment – of both money and time – to strengthen or build an infrastructure to support meaningful co-production at all levels. Doing so would bring them in line with the helpful NHS guidance on Engaging with People and Communities¹. Given their large footprints and diversity of each ICS, much of the hard graft of joining up of care, health and support will need to occur at place and neighbourhood levels. It is here where most connection can be made to people’s lives and their insights, together with those of the workforce will, if taken up, create the most powerful driver for change and improvement and secure the optimum use of resources.
Co-production is fundamental to unlocking the potential of ICSs, particularly at neighbourhood and place level....
Necessary for translating ‘healthy’ visions into practice is shifting to more mature and collaborative commissioning relationships with the voluntary, community and social enterprise sector and other providers, which emphasise innovation, flexibility, and strengths-based personalised approaches. It is also important to support local places for people to come together and create their own solutions. In the words of Making it Real, ICSs should be able to say:
‘We invest in community groups, supporting them with resources - not necessarily through funding - but with things like a place to meet or by sharing learning, knowledge or skills.’
Commissioning more of the same won’t cut it. We need innovative and flexible commissioning that is person-centred...
Leadership in close collaboration
Fundamentally much of the change we want to see and be will depend on instilling behaviours which build trust across those working in organisations at all levels of ICSs, between the centre and ICSs, and with people and communities. Leaders at all ICS levels must have their ‘eyes and ears’ to the ground, reflect on whose voices aren’t being heard, and take pro-active steps to engage. Condition specific priorities in a population with multiple conditions and which ignore intersectionality can be unhelpful and approaches need to reflect the real lives of a local population. That’s why TLAP is going to be adding a Well-Led component to Making it Real, to articulate the role that leaders have to play in supporting effective system integration that improves access, experience and outcomes in ways that people can visibly see. And that leads us on to the question of data and digital.
We need leaders to know their patches....
Data that tells a story
Building on the Covid-19 pandemic experience, great stock is being placed on the use of data and digital to accelerate improvement with a growing demand and expectation of real time data to take the pulse of how the system is performing. Agreeing a common set of metrics for integration should be a vital element to this and we at TLAP are looking forward to seeing early sight of NHS England’s work to develop an ‘integration index’ to gauge whether people are experiencing care that is well-coordinated and person-centred, as we think Making it Real has good potential to be adapted for this purpose.
This is important and necessary as we need to broaden current data sets that have a disproportionate focus on finance and activity data which has the effect of reinforcing the status quo, when we know that so much of what is needed is transformation. The bias from a data rich acute hospital sector compared with other parts of the NHS and social care should be addressed with some ‘levelling up’. Certain principles should be agreed, for example that data is accessible and actionable, meaning that it helps to tell a story of how things are working or not and informs decision making for improvement. There should be greater acceptance and encouragement that rich data can come from conversations with providers and people.
Data should inform action for improving people’s lives for the better rather than used as a tool for narrow compliance....
Assurance we are taking the right steps
The CQC has a potentially powerful and productive role in the new arrangements, with its widened responsibilities from the Health and Care Act 2022 to look across providers, local authority assurance and ICSs. This means that the commission has a unique opportunity to develop a rich and comparative picture over time of what is working well and what needs improvement. We are pleased that the CQC’s Single Assessment Framework incorporates some Making it Real I statements which provides good potential for ensuring that assurance is anchored in what matters most to people. This will be reinforced by the inclusion in the assurance process of people drawing on care, health and support as a way of bringing some true grit to the accountability. ICSs should also be involving people in their own approaches to improvement work and assurance. The oversight should include an assessment of how well co-production is working: who is involved and how this is influencing strategy and services. There are limits to what inspection can achieve and it is therefore vital that continued attention is also paid to fostering a learning culture and organisational development within and between organisations.
Assurance can help build a picture of how things are working out, providing it looks at the right things and involves people with lived experience....
Last steps for now
Like dancing the tango, achieving integration at scale in tangible ways that improve the health and wellbeing of individuals is difficult. The current context makes this more so, but there are some reasons for optimism if steps are taken to undertake intentional action in the areas that I have highlighted to build relationships across organisational boundaries and develop new ways of working with and for people.
I would like to acknowledge the contribution of Chris Naylor, Senior Fellow in Health Policy at the King's Fund and all those members of the National Co-Production Advisory Group and TLAP Team who shared their experiences, thoughts and ideas on integration which have directly influenced this article. Thanks to each and everyone.
Making It Real is an approach for improving care and support, starting with meaningful conversations. It is built around a framework for what good care and support looks like, which was developed in co-production with people with lived experience. Click here to learn more.
¹ Working in Partnership with People and Communities: Statutory Guidance, NHS England, July 2022