By Integrated Care Journal-
By Jacqueline Mallender, Economics by Design, Alastair Mitchell-Baker, Tricordant; Clare Morris, Rethink Partners; Terry Young, Datchet Consulting.
Designed correctly, Integrated Care Systems (ICSs) should deliver care more responsively and effectively than anything to date. By harnessing the latest digital, policy, and organisational advances, with reformed payment mechanisms, ICSs promise better population health across the health-social, primary-secondary and mental-physical care divides.
As always, people are at the heart of the vision: citizens and communities, patients and families, clinical staff and leaders. To work for all, ICSs must focus on the journey each person makes, within a framework of policy, finance and governance.
ICSs are a response to now widely recognised failures in UK health and care delivery but are new to the NHS and are themselves subject to unfamiliar mechanisms of failure as well as success. In this article, we explore four challenges to integrated care – dynamics, delivery, design, and alignment – and recommend a new approach to system transformation.
Effective performance as a dynamic, integrated, system is radically different from the workings of the pseudo ‘internal market’ – with ‘transactional’ characteristics that have defined the last three decades of health and care delivery. It requires a change in mindset, new approaches, guidelines and procedures.
Furthermore, striving for ‘total connectivity’ means that small glitches can generate avalanches of knock-on effects. As systems become more integrated, the firebreaks of traditional provision disappear, and problems can spread further and faster. This means that ICSs must exhibit extreme resilience as they develop.
The second challenge is in how to adapt what we have already learned from radically re-aligning payment methods with outcomes, and incentivise effective collaboration. NICE (The National Institute for Health and Clinical Excellence) has pioneered value-based policy since 1999, making the UK a global leader. An example would be best practice tariffs informed by NICE guidance (for instance in care for heart failure). However, value-for-money does not guarantee affordability within a departmental, local, regional, or annual budget (see Young & Mallender, 2020, Aligning value and incentives to make digital health really work, ICJ), so fresh thinking and new ways of working are needed. But this ambitious goal is well worth pursuing.
While we are born with billions of neurons – grown in months – a brain takes decades to mature because it relies on interconnections, not just functioning units. Similarly, the ICS building blocks – clinics, theatres, equipment – can be built quickly today, but planning the connections between them takes much longer than it used to, while end-users absolutely must be involved from the outset.
This means that the balance between the planning and implementation of care shifts radically. A new mind-set must feel safe with longer planning and design cycles, more concurrency (where very different challenges are addressed together), all underpinned by more agile, adaptive commissioning.
Finally, all ICS partners must align policy and operations across the whole system, including: policies to address variations in the wider determinants of health; operating public health programmes at scale; and providing integrated personalised care and treatment. The science of personalised medicine is well understood but the logistics are new and population health management requires tools that we are still only learning how to use.
The key things to focus on when designing an ICS are:
- Earlier engagement with all stakeholders, including patients and staff, drawing them into the design from the start to unlock value and reduce risk. The old phasing is dead. Long live concurrency!
- Deeper planning that goes right to the final service in operation, this includes: finance, efficiency; the built environment; information systems; digital; organisational structures; and clinical services.
- Scenario testing. ICSs offer extreme performance and vulnerability, so attention must focus on failure modes and unintended consequences, as well as ways to make the most of their versatility and responsiveness in fast-changing crises.
- Agile responses underpinned by automated data and intelligence. Out with old-style monthly KPIs; in with actionable intelligence, always available to all who need it.
- People and relationships: our fates have never been more intertwined than in an ICS. When things go awry – as they will – the quality of relationships will dictate how we respond and stay on track.
Leaders and policymakers will need expertise that is better networked to reach deep knowledge in consensual ways that combines wider skills.
There are no shortcuts for fostering systems as complex and big as ICSs, so look for flexible support that can switch from strategy to technology, to organisational development, to finance, to clinical flows, to resource management, and can be sustained for the duration of development. Experienced hands – but with the curiosity and appetite for the new era – will be hugely valuable.
Don’t forget, our collective intuition has been honed in very different systems, so grill your experts with care before taking them on: you are looking for experience, agility and a wide range of skills, tools and capability.
If comprehensive system transformation is achieved, then providers and policymakers alike can share a wonderful sense of fulfilment, safe in the knowledge that they have created a solid foundation for integration to thrive throughout their system of health and care.
Jacque is an Economist and co-founder at Economics by Design. She is a respected international health and public policy economist and health evaluation practitioner. Over the last 35 years, Jacque has worked across health and social care with a focus on evaluation and health economics in UK, Europe, North America and more recently the Middle East and North Africa. She was a founding convenor of the joint Campbell and Cochrane Economics Methods Group and for 15 years was a committee member. In addition to her work at Economics By Design, Jacque is a Member of the Executive Committee of the Economic Research Council and an Associate of the Oxford Centre for Triple Value Healthcare.
Alastair enjoys working with a diverse range of clients as a consultant – from NHS and councils to international NGOs, government departments and global companies, in the areas of organisation design and development, strategy and systems and leadership development. He has also worked in NHS senior management including as a Chief Executive and a Non-Executive Director. He was co-founder of the European Organisation Design Forum.
Clare Morris founded Rethink Partners after a career in senior health management in the NHS. She has significant experience of delivering integration across health and social care systems with a strong interest in community health, mental health, learning disabilities, children’s services and neurodiversity. Having delivered big changes as an NHS leader, Clare now works with others – at all levels – to make change happen and create the conditions in which integration can thrive.
Terry worked in industrial R&D before becoming an academic and is now Director of Datchet Consulting. With over 30 years' experience in technology development and strategy, health systems, and methods to ensure value for money, his current focus lies in designing services using computer models and he set up the Cumberland Initiative to support healthcare organisations wishing to develop their services more systematically.
A recent paper on the cost-effectiveness of modelling was shortlisted for the Operational Society’s Goodeve Medal: Assessing the value of modelling and simulation in health care: An example based on increasing access to stroke treatment.
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