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Michael Kitts

ICSs, Desmond Tutu and the need for ‘going upstream’

In November 2020, NHSE published a document entitled ‘Next Steps to Building Strong and Effective Integrated Care systems across England’. Its focus was on making ICS intentions, aims and vision a reality, something I absolutely applaud.

The LGA and CIPFA have subsequently critiqued the document, both commenting that the paper (and NHSE’s approach in general) is too health-centric and insufficiently focused on other determinants of wellbeing. I would add that it isn’t genuinely about citizens or residents, rather than patients, and standing in their shoes to understand what would really matter to them and how multi-disciplinary interventions could support them. That is a great shame.

The paper rightly sets out ambitions around more people and place-based approaches and a greater focus on more upstream, preventative approaches, echoing the words of Desmond Tutu. But to make this happen we need to look at things from the other end of the telescope – from the recipients’ end, not the providers’.

I worked for six years in Australia and in one project we looked at how to avoid hospitalisation for older people with chronic conditions. To cut a long story short, of the interventions that had an impact, 75% were non-health related! This type of example totally reinforces the need for multidisciplinary and tailored interventions, rather than traditional (and often universal) services.

Many see integration as combining what is already done – some think of that within a setting such as a hospital, others across settings and providers. Our view is that true integration and focus on wellbeing requires multidisciplinary interventions that are co-created (by commissioners, providers, consumers, VCS etc). Integration is not about services. It’s about doing different things, not combining or doing the same things differently.

NHSE’s paper sets out a number of key requirements to help ICSs secure the intended outcomes. Our experience tells us that in order to to really secure the intended outcomes, 5 key focus areas, all drawing on our unique EDGEWORK approach, need to be addressed:

  • Reframing ambition – complex and multi-faceted system leaders must reframe the problem, using a wider lens and looking across boundaries, to create the space in which system leadership can occur – standing in the shoes of those we’re securing outcomes for. All players need to leave their organisational baggage at the door.
  • Delivering at the front line – change in complex systems is delivered at the frontline; staff and managers need help to embrace and sustain new ways of working, and those providing support require resilience and grit. Front line providers need to be more outcomes and experience-focused, and fully reflect consumer needs. Clinical and wellbeing outcomes are key – but are not the only things that matter.
  • Behavioural change – leaders must recognise, understand and then influence the motivations and behaviours of staff. The currency of success is through change at the frontline. The frontline for ICSs should not be a continuation of the status quo.
  • Managing interfaces – the interfaces between organisations and between residents and public services are where the real challenges lie. New methods are required to deliver sustainable change. These interfaces – between commissioners, providers and recipients – are probably one of the biggest ICS challenges. Provider collaboratives are another key feature here – working together to secure outcomes that matter rather than deliver fragmented services. ICSs need to have a strong market and consumer perspective.
  • Managing trajectories – a different type of performance management and governance that focuses on outcome productivity, and facilitates different management conversations. Focusing on the outcomes that ICSs are there to secure, rather than what they do (and their structures, governance and funding) must be the right way forward. It is time to measure what’s important, rather than making important what’s easy to measure – all drawing on the Triple Aim (of better health for everyone, better care for all patients, and efficient use of NHS resources); the importance of experience cannot be overlooked. It’s also one of the strongest lead indicators of quality and safety issues. Several international commissioners and providers use the Triple Aim as a balanced scorecard – placing as big a focus on outcomes that matter to recipients and their experience of care.

All of this thinking should be supported by data and digital, that again is joined up and supports insights around a 360-degree view of the care recipient and what is being done to support them– not simply drawing on disconnected medical or care data.

Taking Desmond Tutu’s advice on board, early interventions and prevention (rather than post-hoc care) are critical and can be augmented by the likes of predictive analytics and more tailored and focused multidisciplinary interventions. No one body can secure all the support that’s needed – it’s time to genuinely adopt a more ecosystem-based approach. That’s where ICSs need to be. Let’s also intervene in a way that keeps people well, happy and secure, and works for them, not just for providers.

Our passion and experience at IMPOWER is very much centred on whole system approaches, and is focused on improving outcomes that matter, at lower cost. Please reach out to us if you’d like to explore this further.

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