New normal, reshaped NHS

Miles Watson, Laura Cook, Clara McDermott Simarro, Jessica Lewington, Ibrahim Zafar, Kacey Cogle and Madeleine Harris Smith

Even before the pandemic hit, the NHS was experiencing huge changes in how it was delivering its services, with a move towards integrated care at the centre. COVID-19 has accelerated this agenda, with new ways of working being developed in record time as providers looked to combat the virus and the health inequalities it had exposed. Sharing insights from a recent series of conferences on Integrated Care Systems (ICSs), the MHP Health team explore what it all means for the future of the NHS.

‘Local NHS organisations will increasingly focus on population health – moving to Integrated Care Systems everywhere’. This was the headline provision of the NHS Long Term Plan, heralding the rise of ‘active population health management’ rather than the ‘reactive’ care that had preceded. Health and care services would now be genuinely integrated through the enmeshing of primary care, local government, the voluntary sector, local NHS trusts, and anyone with a stake in health and wellbeing into a complex matrix focussed around the specific needs of the local population.

Nearly two years later we are seeing ICSs enter adolescence. Processes and structures are becoming codified, local relationships are being forged, and collective visions are being shared.  But the COVID-19 pandemic has had a profound impact. From revealing pockets of health inequalities, mobilising volunteer workforces, to accelerating the development of organisations through mutual aid schemes, the pandemic has demonstrated just how crucial integrated care can be, and may have just sowed the seeds for the creation of a reshaped NHS and beyond.

Six months away from the original deadline for fully established ICSs in England, what is the state of play? The MHP Health team explore what has been achieved, and what more still needs to be done, in these key sections;

  • How does collaboration work in practice? Lessons from providers
  • What does ‘place’ mean in the delivery of healthcare?
  • How should patients be involved?
  • The role of the third sector in integrated care
  • The evolving use of data
  • How can integrated care tackle health inequalities
  • What does the future look like for ICSs?


How does collaboration work in practice? Lessons from providers

Achieving collaboration between primary care, social care, hospitals and other health providers requires the sharing of best practice, resource optimisation and the adaptation of services to local needs. Addressing these issues will help to iron out current clashes between the architecture of systems and unite providers around a common strategy for healthcare delivery.

In Herefordshire, for example, local directors of three NHS trusts formed a coalition in 2017 called the “Foundation Group”. Their response to the urgent pressures of the COVID-19 pandemic evidenced the success of the coalition by enabling them to make rapid decisions and share best practice,  particularly in the use of technology. Similar lessons can be learnt from the recent ‘provider collaboration reviews’ undertaken by the Care Quality Commission, which have highlighted the successes already achieved in areas prioritising shared governance.

To maximise the success of collaborative working, health providers must embrace a cultural shift towards incorporating the voice of service users and staff into systemic plans. Patients must be empowered to share their experiences with decision-makers; staff must prioritise learning and collaboration; and managers must ensure accountability between healthcare providers. Most importantly, high quality care must be structured around local needs. This will ensure effective management of resource allocation, contracting and systemic organisation.


What does ‘place’ mean in the delivery of healthcare?

The key priorities for health care depend on an accurate and comprehensive definition of place. This definition, according to NHS England, represents populations of 250-500k, with footprints likely matching local council boundaries where there will be clusters of primary care networks (PCNs), one or more acute hospitals, care homes, mental health and community providers, local government and health and wellbeing boards, and voluntary or community organisations.

But what does it mean in practice? Achieving a common purpose across providers through service development and redesign, driving out health inequalities and optimising the use of resources are key priorities for place-based care. Recognising the needs of any given place will enable authorities to position purpose, people and communities at the forefront of healthcare planning and ensure that structures serve to help – rather than hinder – healthcare delivery.

Health providers in Tameside have for example produced an exemplary model of a common strategy centred on place-based needs. By prioritising healthy life expectancy, providers have built on the work of councils in addressing controversial health issues, including obesity, exercise and smoking, and woven relationships with communities into their decision-making processes. A similar shared objective in West Yorkshire – that of helping the poorest first – has improved accountability between health professionals, produced clarity regarding the division of local and regional responsibilities and hardwired both VSCEs and political leadership into the healthcare system.

Both these examples highlight the need for collaborative goal setting at a local level, that penetrates wider systemic objectives through the delivery of care across the footprint.  Decentralisation of the NHS is crucial in allowing local trusts and ICSs to address the social determinants of health which manifest themselves on a local level, such as housing, education and employment. Building the voices of patients and neighbourhoods into systemic priorities will help to ensure that Primary Care Networks and community partnerships contribute to place-based outcomes. Regional systems, in collaboration with political authorities, must also use their position to develop partnerships across delivering bodies, reduce transaction costs and harness the collaborative culture achieved through place-based approaches on a local level.


How should patients be involved?

Patients are the key decision makers when it comes to the delivery of their own healthcare, so their experience matters.  To understand how a patient navigates through the system is the key to a successful ICS.  But this insight is often an afterthought rather than the heart of system evaluation and redesign.

As a way to gather comprehensive patient insight, citizen panels aim to reach a more representative pool of people who may rely on the health system at some point in their life.  These panels are just one type of data collection which should be used alongside other qualitative and quantitative methods, in order to reach all communities in the manner which suits them best, to improve health inequalities and outcomes.

The practice of surveying patients and the population about their experiences isn’t a novel one.  However, as we move to an integrated form of care delivery, patients should be questioned on their experience of care across boundaries, and not just of particular services.  Healthcare providers should also make use of the collaborative nature of systems and share their findings across organisations so as not to unnecessarily duplicate work.  Derbyshire have, for example, established a system insights group to support collaboration between organisations, streamline the insights collection process and create a repository for this data.  There is opportunity for improvement between steps of the patient pathway, not just in siloed organisations.

Patients and citizens have and will continue to provide important insights, but this is only as good as the decision-makers listening to it, enacting change and being held to account.


The role for the third sector in integrated care

Fundamental to effective partnership working, NHS organisations within each ICS must engage with the voluntary or charity sector in their work for it to be successful. With patients and the patient voice at the heart of the charity ethos, charities have long played an important role as a ‘critical friend’ to the NHS, helping to plan and deliver NHS services, and pushing for much needed policy changes to benefit patients.

This relationship was recognised in the NHS Long Term Plan, where NHS England and Improvement committed to transformation funding for ICSs to build joint-working capacity with charities. Measures were also put in place to ensure voluntary sector organisations were represented on partnership boards of ICSs.

The success of these partnerships can already be seen in many regions. In Dorset, for example, NHS providers are working in close collaboration with the Red Cross to ensure patients have health and wellbeing checks once they’ve been discharged and have also worked together to tackle social isolation and loneliness in the community.

As ICSs continue to develop in 2020/21, it is essential that the voluntary sector achieves a parity of contribution and are fully integrated and embedded into the tapestry of ICSs.


The evolving use of data

The COVID-19 pandemic has put into focus how crucial data is to our health system, yet it has also exposed flaws in the current way in which we understand the data that we collect.  For too long the focus has been to collect as much healthcare data as possible through the various avenues available to the NHS.  The thinking was that this was needed to build a complete picture of the current state of the health system. However, in reality, healthcare data should not be considered in isolation from other data sets.

There is a need to look beyond healthcare data to better understand the impact of wider determinants on health and care.  This is especially true when considering the impact the COVID-19 pandemic has had on individuals.  For example, the data from local councils on who was registered for assisted bin collections was a much better predictor of the most vulnerable members of the community at risk from loneliness or social isolation. Pairing this broader data alongside healthcare data paints a more complete picture of the community and highlights where, and for whom, additional support may be needed.

To ensure the health service is as efficient as possible there must be more sharing of broader community data sets, such as those belonging to local services, between boroughs across the country.  What has been shown so far is that to develop digital solutions the focus must be on sharing innovative thinking between communities.


How can integrated care tackle health inequalities?

Health inequality, as in many areas of health policy, is a victim of the clash between top-down versus bottom-up approaches. In the ‘top-down’ corner, we have the Long Term Plan, with an entire chapter dedicated to strategies on how to reduce health inequalities, supported by swathes of data. In the ‘bottom-up’ corner, we have lived experienced of not just patients, but healthcare professionals and local providers too.

So where does success lie? Well, not in pitting one approach against the other, but finding a way for the two to work together. In Central and North West London NHS Foundation Trust, a provider that supports the community affected by the Grenfell tragedy, Fatima Elguenuni has come out of retirement to use her experience as a therapist and mental health practitioner in a new role as a Cultural Consultant.

Fatima has described the difficult relationship between the local authorities and the community after the tragedy – they did not know each other. The community felt isolated and unsupported, and the system and services felt hard to reach, using unfamiliar ‘top-down’ language in order to meet their system goals. Despite those on the front line doing their best and the community needing care, they weren’t connecting.

So when Fatima started in her new role, she set herself a challenge; “How do we design and deliver an integrated well-being service, using what we know already works, to engage and respond to the diverse needs of this community?” Fatima tested out new approaches, but also used her joint position as a local, well respected member of the community, and as a healthcare professional, to hear the needs of the community and deliver them within NHS structures. Fatima says that to implement the changes required to deliver seamless integrated care, each system will do this in the way that best needs the need of their own population; each system speaks a different ‘language’. Ultimately, she says, this language will be formed through real engagement with the community.


What does the future look like for integrated care systems?

In 2020, the year of the COVID-19 pandemic, one of the key challenges that integrated care systems are tasked with; tackling health inequalities, has never been starker. The importance of linking up physical and mental health services, primary and secondary care and NHS and local authorities is key.

COVID-19 has sped up the need for ICSs to transition from planning to delivery. As has been outlined, there have already been some significant success stories around this.  From supporting patients with better self-management using digital and tele-health services, to the establishment of a significant volunteer workforce and mutual aid schemes across the country, the local response has been extraordinary.

But what next?  We’ve seen integrated care revolutionise the way we think of our health service – for the better. In 2019, the NHS Long Term Plan set out a roadmap to cover every region of the UK with ICSs by April 2021, and our need for this ambition to be realised has never been greater. So how can ICSs ensure that the changes that have been achieved over the previous six months can be honed and improved?

Through this blog we’ve explored some of the key building blocks needed in these next steps; putting the patient voice at the heart of ICSs, expanding partnerships, establishing local relationships and accountabilities, and more effective data collection and sharing across services.  Financial frameworks must be developed to support local advocates to lead and grow their systems.

Finally we must not neglect the need for national leaders to support this significant devolution with a clearer legislative framework, to support strong governance processes, consolidate progress, secure the right level of national scrutiny and accountability and support those key workers on the front lines up and down our country.