Introduction to leading and managing better care

Why integration is important

Health, social care and other public services are facing unprecedented demographic and financial pressures. In just 15 years’ time, the number of people over 65 is likely to have grown 50 per cent and the number of over-85s will have doubled. Demand is also growing from working-age people.

Current services are fragmented between health and social care, acute hospitals and primary and community services, and between physical health and mental health. They will increasingly fail to meet the needs and expectations of people who are living longer with a mixture of long-term health conditions and other needs that require joined-up, integrated care. The focus has to shift from treating illness to supporting people to stay healthy and independent for as long as possible. Integration is key to finding more effective and sustainable ways of achieving these goals.

The Department of Health and Social Care (DHSC) and partners within the National Collaboration for Integrated Care and Support agreed a definition of integrated care based on the National Voices narrative for person-centred coordinated care (2013).

My care

My care is planned with people who work together to understand me, and my carer(s) put me in control, and coordinate and deliver services to achieve my best outcomes.

• My goals/outcomes: All my needs are assessed and taken into account and I am supported to understand my choices and to set and achieve my goals. The needs of my family and carer are recognised and they are given support. My care and support helps me to live my life to the best of my ability.
• Information: I have the information at the right time, and with the support to use it, to make decisions about my care and manage my condition(s). I can see my care records at any time and decide who has access to them.
• Care planning: I work with my team to agree a care and support plan – I know what it is and have as much control as I want about the kind of support I need and how I receive it.
• Communication: I tell my story once, I am listened to about what works for me and my life. I am always kept informed of the next steps. The professionals involved in my care talk to each other and work as a team. I always know who is coordinating my care, they understand me and I have one point of contact I can go to with questions at any time.
• Decision-making including budgets: My carer and I are involved in discussions and decisions about my care and I have help to make informed choices if I need and want it, I know how much money is available for my care and I can access this and determine how this is used or get skilled advice about this. Care planning: I work with my team to agree a care and support plan – I know what it is and have as much control as I want about the kind of support I need and how I receive it.
• Transitions: When I use a new service my care plan is known in advance and respected. When I move between services/settings there is a plan in place for what happens to me next; I know where I am going and who will be my point of contact.

Better Care Fund (BCF)

The Better Care Fund (BCF) was set up to drive integration between local authorities and the NHS and to pool resources to help achieve this. In 2017 it was expanded with additional money which was allocated directly to local authorities. The Better Care Fund is one part of a wider set of measures to achieve the closer integration of health and social care. Other activities include:

• Sustainability and transformation partnerships (STPs) have been developed in 44 ‘footprints’, aligning to health and social care economies, across England. These set out how organisations in local health and care economies can plan effectively and deliver more integrated services. Local Better Care Fund plans need to be aligned with these wider system-level plans.

• The NHS Long Term Plan sets out how the NHS will continue to transform and integrate over the next decade, with specific commitments over the five years to 2024 to break down the barriers between health and social care, physical and mental health and primary and acute care – the triple integration aim.

  As part of this, all sustainability and transformation partnerships are expected to develop to become integrated care systems (ICSs) by 2021. ICSs will have a key role in working with local authorities, and with commissioners making shared decisions with providers on how to use resources, design services and improve population health.

  The Long Term Plan also commits to a shift towards community and primary health, with an additional £4.5 billion to be spent on primary medical and community services by 2023–24, including investment in reablement services, crisis response and enhanced health care for people living in nursing and residential care homes. Delivery of this commitment will need health and care commissioners and providers to work closely together deliver these services.

  The Long Term Plan sets out the importance of local government in delivering these commitments, and many others and sets a clear expectation that local authorities should be partners in ICSs.

• Integrated care systems (ICSs) will be 'evolved' versions of a sustainability and transformation partnerships, working as a locally integrated health system. ICSs are central to the delivery of the Government’s Long Term Plan. Within the new system, NHS organisations (both commissioners and providers), often in partnership with local authorities, choose to take on clear collective responsibility for resources and population health. They provide joined-up, better coordinated care. In return they get far more control and freedom over the total operations of the health system in their area; and work closely with local government and other partners to keep people healthier for longer, and out of hospital (NHS England (2017)).

• Integrated personalised commissioning Building on the learning from integrated personal commissioning (IPC), NHS England published its vision for personalised care in January 2019. This includes a comprehensive model for personalised care that brings together six key components:

  • shared decision-making
  • personalised care and support planning
  • enabling choice, including legal rights to choice
  • social prescribing and community-based support
  • supported self-management
  • personal health budgets and integrated personal budgets.
     

  There are currently 21 demonstrator sites, including three integration accelerator sites (Lincolnshire, Nottinghamshire and Gloucestershire) who are implementing this model. Learning will be shared as soon as available on the NHS England. The programme includes:

  • In Lincolnshire, Nottinghamshire, Nottingham and Gloucestershire, the council and the NHS are introducing joined-up assessment and personalised care and support planning for people who have health and social care needs.
  • Tower Hamlets is working across health and social care to provide people with integrated provision across wheelchairs and home equipment.
  • In Gloucestershire and Hampshire, the NHS and local government are working together to train staff to deliver personalised care. Other parts of the country are encouraged to consider this approach, and how they can plan to support the roll-out of this comprehensive model including joint working to expand the use of joint assessments and care and support planning, integrated personal budgets and expand social prescribing schemes in partnership with primary care networks.

Tools and resources

Shifting the centre of gravity (LGA, NHS Confederation, ADASS, NHS Clinical Commissioners, NHS Providers and ADPH) is a self-assessment tool designed to support local health and care leaders to critically self-assess their ambitions and capacity to deliver integrated care. This includes the basic elements of good programme management:

• Is there an appropriate programme plan to transform the local health and social care system and make it sustainable?
• When will it happen?
• Who will lead what? And who will be involved?
• When will decisions be taken?
• When will ambitions be delivered?
• Have clear milestones and checkpoints been agreed?

Integrating care is difficult

An important lesson from over 30 years of different policy initiatives is that achieving integrated care is hard to do. However, there are certain factors that can make the difference between success and failure. These have been identified consistently in national and international evidence and research over many years and have been used to develop the structure of this guide:

• Leading a system
• Leading change
• Delivering integrated care
• Engaging and communicating

A key success factor is strong, shared and collaborative leadership, focused on outcomes that matter to people. Traditionally, senior managers have been expected to provide leadership within their own organisations, including the management of change programmes and internal communications. But integration requires change to happen across different sectors, organisations, professional disciplines and geographical boundaries. Leadership across the whole system is needed as well as leadership within each organisation.

This guide addresses both organisational and system leadership and how this can help make local integration plans a reality. It draws on research and from practice in places around the country. It is not a step-by-step instruction manual – developing leadership should always take account of different local needs and circumstances.

The guide should be complemented by a range of implementation support tools such as workshops and online learning. The checklists included in the guide focus on the most common areas and can be used as prompts to consider other models, tools and techniques.

I'm committed to ensuring that NHS England plays its part in shared system leadership… it’s not a few heroic individuals: it’s a different type of leadership and a more nuanced range of management skills and behaviours.

Simon Stevens, Chief Executive, NHS England at the King’s Fund Annual Leadership Summit, November 2014

How do you develop system leaders who see beyond the boundaries of their organisations? I think you have to do it in many ways. My senior leaders and my colleagues in other organisations have to develop a critical mass of people who believe in it, and behave it. Not all of them feel the same because they have so much going on in their own organisations that they cannot see beyond that. But when we do, we need to give people the tools and have a performance management system that requires collaborative working. So we have just put in a big learning and development programme, at the heart of which is building confidence and competency about outward-facing collaboration in our staff.

Joanna Killian, Chief Executive, Surrey County Council

Case studies

• Greater Manchester – co-design and cooperation Open

  Greater Manchester has made more progress than most, with its strategic plan having been agreed around a year before STPs were introduced in the rest of England as part of its devolution agreement with the government (AGMA et al. 2015). The plan was developed ‘on the principles of co-design and collaboration’ and is focused on people and places rather than the different organisations that deliver services. It is a practical example of the shared purpose and vision needed to underpin system leadership.

  Greater Manchester has also put in place leadership and governance arrangements to support joint working. This builds on the work of the combined authority, which was formed to support system leadership across local authorities.

  The leader and chief executive of Manchester City Council were central to this process and to the work now being done to engage NHS organisations in the wider devolution agenda. Frequent personal contact between leaders in local government and the NHS have helped in this process.

  Source: Leading across the health and care system: lessons from experience, The King’s Fund (2017)

• Using common resources – Leeds and Salford Open

  A number of places are seeking to look at the bigger picture by focusing on the use of their common resources, such as ‘the Leeds pound’ and Salford Together. Organisations and their leaders work collaboratively in taking decisions in placebased systems rather than focusing on what is in their own interests. In Salford, the CCG and the council have created an integrated commissioning committee to oversee the commissioning decisions for all adult health and care services across the resident population.

  Source: Leading across the health and care system: lessons from experience, The King’s Fund (2017)

• International case study: Canterbury District Health Board, New Zealand – one system, one budget Open

  The experience of the Canterbury District Health Board in South Island, New Zealand, is a living example of what can be achieved through a long-term commitment to system leadership. Faced with a growing and ageing population, and the prospect of having to build a second acute hospital to cope with rising demand, leaders in Canterbury committed to working together as ‘one system, one budget’ even though it was neither a single system and nor did it have one budget. The district health board acted as a catalyst in this process, bringing together clinicians, managers and other stakeholders to plan services for the future.

  Through an extensive process of engagement across the community, agreement was reached on a shared vision of a single integrated health and social care system in which patients were at the centre. The key strategic goals were that services should enable people to take more responsibility for their own health and wellbeing; as far as possible people should stay in their own homes and communities; and when people needed complex care it should be timely and appropriate.

  These goals were pursued in diverse ways including developing a shared electronic record and a system for managing demand for hospital care, avoiding admissions where appropriate, and investing in community rehabilitation.

  None of this would have been possible if leaders in different parts of the system had not been willing to collaborate in the development and implementation of the plan. They were able to do so because of continuity in the leadership community, familiarity developed over many years, and by developing a high level of trust. Many of those involved had moved between different leadership roles during their careers and therefore understood what it was like to ‘walk in each other’s shoes’.

  Source: The quest for integrated health and social care: a case study in Canterbury, New Zealand, The King’s Fund (2013)

• North West Surrey Open

  North West Surrey (NWS) has launched an integrated care programme to address the challenges faced by older people with complex health and social care needs.

  They are developing a new primary care-led ‘locality hub’ model of care for frailty that will focus not only on providing swift reactive medical and care interventions to complex frail patients, but also on the provision of proactive wellbeing services. These will promote greater independence, improved quality of life and will prevent social isolation.

  The programme has established strong sponsorship at all levels. An integrated strategic change board oversees programme delivery, while an integrated core design group with senior level representation from primary care, community care, social care, the local acute trust and mental health, oversees the design.

  Strong leadership has been critical in progressing this work by bringing the necessary people together. The core design group has been meeting after-hours every two weeks to drive out the clinical model of care, and work has now started on detailed operational planning.

  For more information visit North West Surrey CCG

Checklist – integrating care at scale and pace

There is no single best way of integrating services but evidence and experience offer some important lessons.

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Source of checklist: Making integrated care happen at scale and at pace, The King’s Fund (2013)