Managers working together to achieve better joined-up care

Challenges

• The role of practitioners and managers in joint arrangements can be unclear.
• In a joint team the manager’s job is made harder because staff have a wider range of roles and needs and they are going through the uncertainty of transition.
• It’s hard to sustain the commitment of time and energy to lead a team through change on top of the day job.

Key actions

• Ensure managers have the time, support and investment they need.
• Provide joint management training and set up joint management meetings. Skills for Care has produced a helpful Manager induction standards guide.
• Ensure clear and consistent communications. For further guidance visit the NHS Confederation’s Reconfigure it out publication for good practice principles for communicating change.
• Explore practical levers, including colocation, joint appraisals, learning and sharing information, as trialled in the West Norfolk Alliance Pioneer Programme.
• Implement structural mechanisms, including joint or shared performance frameworks and shared management posts, like the Joint Accountability Framework in West Dunbartonshire.
• Look at sharing money across organisations to underpin joint working, for example, where budgets have been pooled as part of the Better Care Fund.

Translating joined-up strategy to joined-up delivery

Understanding, buy-in and culture shift among operational managers is crucial as they will set the tone and lead their teams in new ways of working. Even if senior leadership is clearly committed to change, managers have to operate in an environment of uncertainty, juggling different and sometimes conflicting priorities. Engaging managers at all levels in a clear vision, demonstrating their particular role and contribution in developing joined-up care, is pivotal to success.

It is really important to have a clear plan as to how this can be done. This section explores the range of levers that can be used with a range of managerial roles including service managers, commissioning managers, heads of service and team leaders. It provides practical advice about how to approach joint working at an operational management level, as well as examples of what has worked elsewhere and why.

A clear mandate

Managers need a clear mandate and framework that sets out their role in developing joined-up care.

This mandate should describe how much freedom and autonomy managers have to experiment with different ways of working so that they can find the right balance, collectively with their team. Managers need to have the confidence (and implicitly, the support) to leave their traditional comfort zone and test different approaches. An effective joint working system will ensure clear lines of accountability while allowing freedom to innovate at every level.

Empowering staff

Managers need to support frontline staff to focus on outcomes for people, not on tasks or processes. This is a major shift and should be considered as part of their ongoing development and performance plans. Doing this well will remove some of the perceived threat around new ways of working. Many practitioners will welcome greater freedoms in how they apply their professional skills.

Managing a joint team

It’s vital to spend time gaining a real understanding of where the people in your joint team have come from and what they have been used to in their previous organisations. Think about what’s different for them – the language being used, the place they are working, the IT system they are using, the colleague(s) they sit next to.

Have conversations with staff to understand how they see the changes, and which ones might be more painful than others. Work through them with patience and support. Empathise with the loss that takes place and stress the improved outcomes of the new joint ways of working. Small changes can make a big difference to the way an entire team interacts.

Continuing commitment

The behaviours and skills required from managers for joint working might be hard to maintain in the face of day-to-day priorities. Sustaining energy and effort is essential to ensure that joint working ‘sticks’ and becomes the cultural norm. Managers should look to allocate a specific percentage of their time to promoting and actively driving this change, and their line managers should support them in doing so. Bringing together a disparate group of practitioners into one team with a shared purpose is hard. However, there are many tools available to encourage a single team mindset and a focus on outcomes.

Unless the whole system changes, services cannot make a real difference to people who have multiple, long-term conditions. It is about getting the right people together in a room to bring about change and the meetings are based on delivering outcomes. [For us] those partners are: director from KCHT Sue Scott; assistant director West Kent Mary Silverton and integration programme lead from KCC Jo Frazer. Without their commitment and sincerity to deliver the pioneer objectives the work streams would not be as far developed. We are now networked and hash tagged with national partners and sharing best practice through teleconferences.

Sue Excell, Service Manager for West Kent and Clinical Lead for Integration

Effective management of joint teams

Managers need support and investment to manage joint teams effectively, including being allowed the space and time to reflect on what is working (or not!). Establishing joint management meetings will bring to managers’ attention the day-to-day problems of creating joint services. Managers should consider the following:

• Co-location: physically bringing people together so they are based in the same office or place. This creates day-to-day interaction and communication which, in turn, generates a new joint culture, e.g. in the West Norfolk Alliance Pioneer programme, where integrated operational management brings together community health and social care.
• Use appraisal schemes to ensure consistent joint objectives for managers, and help remove any conflicting targets – focus on shared objectives and outcomes across the management team.
• Pool resources: including staff, offices and management systems.

Managers are often caught in the middle, between people who use services and the strategies and plans of senior leaders. The role of managers needs to be set out clearly in the overall narrative for joined-up care that connects the strategy and plans with the benefits for people with care and health needs.

The role of joint management training is vital. Developing shared common qualifications and joint learning will embed ‘jointness’ and ensure it is recognised in a common way. Skills for Care’s Manager induction standards is a good place to start.

Given that many of the most serious risks to service change programmes relate to communication and engagement, the role played by communication and engagement leaders is crucial. Although there are some key themes for strong engagement, such as clear language and consistent messaging, communications should be tailored to meet the needs of different audiences. This can include both the content of the message and the most effective way of communicating it. See How to... lead and manage better care.

The NHS Confederation also provides information on Good practice principles for communicating service change in the NHS.

When managing joint teams, remember the following:

• Form joint action learning networks to allow space for reflection and encourage frank and honest dialogue at management level across organisations (e.g. the Scottish Social Services Council’s action learning sets were commissioned to bring senior managers, social services and health together to work on the issues that prevent good and improving outcomes for those who use services).
• Spend ‘a day in the life’ of a manager colleague from another organisation. Actively encourage job swap days across organisations to build insight into other people’s roles, responsibilities, priorities and ways of working.
• Use information-sharing platforms that will enable collaboration and the sharing of materials (e.g. Camden CCG’s use of Huddle ).

There are lots of examples of joint or shared performance frameworks which can be drawn upon to standardise an approach, such as the Joint Accountabilities Framework in West Dunbartonshire.

The Scottish Government has set guidance on the principles for planning and delivering integrated health and social care and a set of core indicators to measure progress.

In Greenwich, joint management posts have been created across health and social care. Integrated management is assured through having a Royal Greenwich assistant manager where there is a NHS manager, and vice versa: see Innovation in social care.

Sharing money can help erase traditional organisational boundaries: pooled operational budgets such as in the Staffordshire and Stoke-on-Trent Partnership Trust can also support effective joint management.

Shaping the workforce offer

Sites involved in the Skills for Care programme include representatives from the pioneer sites, Health Education England, Public Health England, the Association of Directors of Adult Social Services, Skills for Health and NHS England. They have developed a programme based on workforce needs identified by the sites.

The priorities are:

• understanding the size and shape of the workforce for integration
• designing and redesigning the existing workforce with the right values
• skilling the workforce
• developing a diverse market, focusing on workplace culture.

The group has identified the need to ensure that the focus of work crosses all service areas and is not predicated on older people.

Shaping the workforce offer: Work programme – an overview

To view a larger version of chart, download a copy of the full report.

Source: Shaping the workforce offer work programme (2014) (Skills for Care, Skills for Health, Public Health England, Mental Health Forum, ADASS, NHS Health Education England, NHS Improving Quality)

How can this learning be applied?

Developing joined-up care is a change process that will only be achieved through managerial behaviours that actively learn from what is happening day-to-day. These include:

• taking a proactive approach and not waiting to be told about mistakes or omissions
• treating complaints as opportunities to learn and improve
• using the insights of local Healthwatch and other groups representing people who use services
• seeking out feedback from staff.

It is always important to share learning. No one is getting this 100 per cent right, and being able to evaluate how things are going with colleagues can help. For example, mentoring across sectors is hugely rewarding from both a mentor and a mentee perspective.

Staff should be encouraged to speak up about their concerns. It is important that they feel able to express their views and highlight any concerns. Whistleblowers should always be protected.

Refer to information about pooled budgets and section 75 case studies in 3: Pooling budgets and agreeing risk share in How to... bring budgets together and use them to develop coordinated care provision.

Skills for Care undertook an evidence review of integrated health and social care in October 2013, and discovered that:

• effective management of integrated teams is key to successful integration
• team management is different, and should be separated from clinical or professional management
• separate management structures do not support integrated approaches to delivery.

Managers‘ checklist

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