The problem of DTOC has basically been addressed, but the problem of demand most certainly has not.
At an event I attended last week, the King’s Fund released their findings on the development of Integrated Care Systems and the lessons we can learn from those at the forefront of the move towards integration. The report reveals positive signs of progress in delivering service changes at a local level.
Having listened to some of the pioneers speaking at the event, a number of points stand out to me:
- There is no roadmap for integrated care. Integrated Care Systems are not responsible for delivering care; their purpose is to bring organisations together to join up the planning and commissioning of care in a local geographic area. This means there is no ‘one size fits all’, so locally there needs to be an inclusive ambition built on trust, and a willingness and commitment to work together. That would shift ingrained leadership styles and perspectives, enabling those involved to look beyond their own boundaries and collectively see the bigger picture.
- It is time to focus on relational rather than technical challenges. Too much time has been spent talking about organisational forms, pooled budgets and removing the barriers that caused a fragmented health and care system in the first place. Health and social care actors need to focus on integrating the actual delivery of care, starting by addressing system leadership and collaboration, and by building trust and setting a vision. For that to work, there needs to be a fundamental shift in mindsets, cultures and behaviours, with honest and open conversations about the direction of travel and where to start.
- A population health approach will deliver sustainable change. Transformational change is not achieved by looking only at someone’s presenting health or social need; the solution needs to take a holistic view of the people who the services are for. Historically, decision makers haven’t listened to communities because they didn’t want to hear their problems, but it is only possible to design and deliver effective services for people if you understand those people and the communities they live in. The challenge is how to spread, build and construct a population health system built locally for local needs, and it is necessary to utilise existing community neighbourhoods better as they are fundamental to mobilising local change.
- There is a need for different conversations. Previous attempts at integration have generally started with health partners, but most health professionals have deficit-focussed rather than asset-focussed conversations with their patients, which drives dependency and works against the move to resilience and self-reliance. There is a need to transform these conversations, to support people to take a risk, and empower them to be their own Director of Public Health. We need to take a deal-based approach to every contact, using ethnology to think about an individual’s assets and strengths, and encouraging them to support themselves or use alternative community resources where possible.
- The wider determinants of health must not be forgotten. We are hearing more often from both health and social care professionals that housing and financial problems, and social isolation, are massive drivers of demand in the system. However, these challenges cannot be addressed through traditional, formal health and care solutions. System actors need to turn to communities and the assets within them in order to prevent some of the longer-term health and wellbeing problems.
In summary, we have to recognise that integration is not transactional, it is about building local relationships and trust at all levels from senior leaders to frontline staff, and needs to be person centred. That will take time, and embedding sustainable transformational change into culture and behaviours is not easy. Persistence is required.