Lessons learned from Local Systems Reviews Support Programme
The journey through the health and care system
The Department of Health and Social Care (DHSC) commissioned the Care Quality Commission (CQC) to undertake a programme of targeted local system reviews in 20 local authority areas with the aim of understanding how services are working together to meet the needs of people who move between health and care services. The focus was people aged over 65.
SCIE was then asked by the DHSC to provide independent support to local systems to assist with the development of plans that addressed the findings and recommendations from CQC’s local system report ‘Beyond Barriers’ (CQC, 2018) (see summary below).
Here we share some of the insights gained by SCIE from the independent support to the local systems. These insights will be valuable to leaders with responsibility for developing integrated working within health and wellbeing boards, local authorities and clinical commission groups – including chairs and chief executives.
Any area developing plans to tackle the interface between health and care should:
- engage all local partners in planning, including people who use services and carers, the voluntary, independent and community sectors
- clarify, and where necessary, create or strengthen governance arrangements to ensure ownership and delivery of action plans are clear
- align plans with existing programmes
- balance short-term fixes with longer-term, sustainable improvements
- consider the use of external facilitators to challenge and support planning.
The state of local systems
Localities were largely very open to the challenges presented in the reviews. For example, sometimes acknowledging that they were running more disjointed schemes than they had appreciated, leading to variation in care and often poor service users’ experiences and journeys through the system. The CQC’s emphasis on strengthening system alignment and having a shared vision was appreciated.
Local leaders acknowledged that the local system reviews provided an independent, comprehensive, cross-system synopsis of local areas’ strengths and areas for improvement. They helped to identify the root causes of deep-seated problems, and increased leaders’ confidence in where to invest improvement effort for maximum gain.
CQC findings: summary
Organisations intended to work together but mostly focused on their own goals.
Although there was good planning between services, the way they were funded did not help them to work together.
- were prioritising their own goals over shared responsibility to provide person-centred care
- did not always share information with each other which meant they weren’t able to make informed decisions about people’s care
- were not prioritising services which keep people well at home
- planned their workforce in isolation to other services.
System vs provider performance
Even where individual services were considered of good or high quality, the system as a whole can be vulnerable, functioning poorly and needing to improve.
Leaders grappled with system complexity, whilst at the same time trying to develop a better understanding of what it means to be accountable for a whole system.
Often the system’s difficulties were relationship-based, but they also stemmed from the many external factors seen as adversely influencing joint working and cooperation, such as:
- the stability of the local health economy and financial constraints
- competing policies, performance frameworks and political priorities
- the maturity of partnership working
- the strength of system governance.
Defining the local system
Defining what constitutes the local system can be challenging. For the purposes of this review, CQC defined local areas as those covered by a single health and wellbeing board, (i.e. local authority footprint). However, evolving national policies and a challenging regulatory environment, especially within the NHS, were seen as affecting the capacity to find solutions on just that footprint. SCIE encountered some strong views about sustainability and transformation plans (STPs), which are seen as having little logical geographical relationship to the concerns of local councillors.
In areas where CQC found the health and wellbeing board to be less effective, there was some scepticism about the role of the boards. For example, some were seen as weak in terms of providing system oversight. And there was some confusion about who sets local priorities – commissioners or providers – in the reality of competing priorities and performance frameworks.
This scepticism was not observed everywhere. For example in one area the board had a good handle on the local system issues and seemed to be performing a valuable role. In another, a key issue was how to relate review findings to wider transformation plans already underway.
Some providers had concerns about the complexity of tackling patient flow. From their vantage point, solutions to system blockages needed to come from a wider geographical footprint, since their catchment area was not coterminous with the local authority being reviewed.
Where the area had strong and well-established leadership, leaders were able to grasp the challenges rapidly and then discuss specific actions. Their action plans emphasised alignment with existing strategies and improvement programmes.
Where systems and relationships were more fragile, immediate actions were taken to restructure system governance and tackle what one person described as ‘our system leadership vacuum’.
System leaders were keen to ensure there was a joint infrastructure in place to deliver the action plan in response to the CQC review.
Defining the local system also involved considering who is part of that system, and who are its leaders.
This prompted local areas to think more broadly about how best to engage with a wider range of stakeholders and contributors to improve care experiences and outcomes across sectors (independent care providers, voluntary and community organisations, housing).
Solutions to better managed care at home or outside the hospital were seen as requiring greater engagement of GPs and other providers of primary and preventative care.
The involvement of experts-by-experience in the planning process was valuable, but not consistent in all areas. This was a missed opportunity. When they were invited, the local Healthwatch made strong and useful input at many summits.
One organisational leader regretted not having more people who use services present as these would have ‘driven less siloed discussions’.
Effective action planning
Action plans were designed to ensure a whole-system response and maintain a focus on practical actions and alignment with existing strategies and improvement initiatives.
The focus of the action plans varied from area to area, and included managing:
- rising demand, especially in acute and social care
- the capacity required to undertake development/transformation work whilst maintaining existing activities
- the balance between the demands of individual organisations with priorities that required broader contributions to system working and development.
To assist health and wellbeing boards to approve the plans and to enable ongoing oversight, the plans included an overview of progress achieved since the CQC review visit, a summary ‘plan on a page’ and clear quick wins.
Alignment with existing programmes
Wherever relevant and helpful, action plans were deliberately aligned with existing strategies and improvement programmes, such as the Better Care Fund or urgent and emergency care strategies. These became documents embedded in the final action plan itself. In many instances, where system leaders were already making progress with existing plans, the CQC review helped them re-prioritise or accelerate actions that would lead to better system flow.
Longer-term actions were the most difficult to pin down in the action plans. For instance, market shaping and workforce development were critical long-term challenges facing all the local areas. The absence of quick fixes and the longer time horizon for resolution suggest that support may be needed to create the necessary system capacity for managing system flow.
Delivery of action plans
Effective governance structures and ways of working were seen as critical for collective ownership and delivery of the action plans. The health and wellbeing board was considered the critical body for overseeing system changes, but not all were fit for this purpose. In some areas, the board’s ways of working were seen as requiring overhaul to fulfil a more proactive and challenging role. In many areas, sharper role differentiation between STPs, integrated care systems and health and wellbeing boards was needed.
Where the CQC reviews highlighted deficiencies in system governance and partner relationships, the action plans directly addressed the mechanism for monitoring and assuring the delivery of the improvements. A small number of places chose to create separate improvement boards, but most preferred to use their existing health and wellbeing boards and executive leadership groups, or other local vehicles such as urgent care boards. In some cases they stepped in to strengthen these arrangements.
Some areas simplified existing governance structures, reviewed the composition of executive boards and programme teams, and streamlined their functions.
Most action plans were aligned with existing system transformation activities, from delivery of the High Impact Changes model, to the development of place-based integrated care. Many areas indicated that they already had support arranged or were able to draw down transformation funding (e.g. in Greater Manchester). SCIE consultants put local areas in touch with exemplars, places where people were already doing these things well. This type of support was both sought and welcomed.
Managing delivery of action plans
To deliver the action plans, local areas should consider having:
- a dedicated resource, such as a programme manager charged with delivering the plan
- a shared pot of funding to support the improvements prioritised in the plan
- good governance in the form of executive leadership, with the director of adults’ services being an essential part of the board or team.
Several themes emerged from the action plans which suggested that local areas may require support on key issues in the future including:
- working with independent sector partners to grow market capacity and evolve provision, such as creating different types of care packages
- workforce development, capacity and capability
- transforming data into intelligence to better manage flow
- improving joint commissioning (not delegating this to procurement teams)
- improving two-way communications across the system, including with frontline staff.
Independent support from SCIE
SCIE’s independent support, expertise and facilitation was welcomed by local leaders. They valued the external challenge which helped local partners to generate and maintain a shared commitment and focus. They also valued SCIE’s knowledge about the range of support available to them and which areas were tackling similar issues.
Person-centred integrated care: SCIE consultancy support
SCIE are leading experts in supporting organisations and local areas deliver person centred and integrated care. Our approach is evidence based, coproduced with local stakeholders and people who use services and focused on improving outcomes.
We are delivering numerous national and local initiatives, including the Better Care Fund support programme, evaluation of Integration Accelerator Pilots and post CQC’s Local Systems Reviews Support. We provide:Diagnostics and analytics
We use our DHSC/NHS England endorsed Logic Model to diagnose where local areas are on journey towards integrated care. Our analysts work with you to identify areas for improvement and action.Evidence based planning and implementation support
We help local partners draw up strategies and plans for person-centred integrated care based on the latest evidence. We help local areas work collaboratively to implement best practice models of integrated care.Co-production
We help you design, commission, deliver and evaluate integrated care services with people with lived experience and carers.Supporting national networks and learning
We develop national evidence based support tools, run national and regional masterclasses and webinars and facilitate learning networks