In this guest blog post, Sally Markwell, senior lecturer within the Oxford School of Nursing and Midwifery (Oxford Brookes University), explores how working together across Integrated Care Systems moves us from marginal gains to big impacts.

Organising for action

In his recent HSJ Comment piece ‘making diamonds out of sausages‘, Health Economics Unit (HEU) Director Andi Orlowski explained that integrated care systems offer us a space and have the right people around the table to draw the skills needed from the system, not only helping to find the resource (data) to mine, but also helping people better see the broader context and organise themselves to action the answers across traditional boundaries of both provision and sector.¹ 

Our ‘great expectations’ of data mining in this context are focused upon the outcomes we can expect by working together. By using Population Health Management approaches the NHS, Public Health, Local Authorities and a whole host of arms-length bodies, charities, and other government organisations can focus on the wider determinants (the big gains rather than healthcare’s marginal gains), improving outcomes and saving money- allocative efficiency.

Alien terrain

However, being around the ICS table isn’t necessarily a natural habitat for these stakeholders, and we continue to hear reports of ‘strained and challenging relationships’ between commissioners, providers and the local authority². Our expectations have been salutary in terms of the numerous red flags raised as the ICS process evolves; Instead of partners accepting mutual accountability for performance and supporting each other to improve, concerns have been identified over the potential for hierarchical behaviours to take precedence.

This means the opportunity for ICSs to be distinctive in their ways of working is being lost. Relationship building is also a key challenge². Sir Chris Ham highlighted the importance of safeguarding against this and requests that ICSs focus as much on strengthening relationships as developing governance³:

Almost any arrangement can work if the people involved want it to succeed based on a shared vision of what they wish to achieve and a willingness to come together for the good of the population they serve.

There are further red flags idenitified in terms of potential conflicts for providers, their Board members, officers and employees when discussing or taking decisions on matters within different constituent parts of the overall system⁴.

Participative and facilitative ways of working

As the vision for the NHS has changed, so has the perspective on how we in the NHS work together. Transforming systems is ultimately about transforming relationships among people who shape those systems. This requires a fundamental shift from pace-setting leadership styles to participative and facilitative ways of working. It means being open to hearing and acting on different points of view. This in turn is dependent on creating time and space for stakeholders to come together to have the creative conversations on which understanding and change rest.⁵

The perception of developing relationships both within and external to the NHS has clearly changed over the past decade. With subsequent emphasis on organisational autonomy, competition and the separation of commissioners and providers, fundamentally shifting towards a system of integrated care which depends instead on collaboration and a focus on places and local populations as the driving forces for improvement. These shifts in perception have seen the evolution of working together through information sharing and the creation of informal relationships, towards increasing consensus and more formal relationships through collective planning and joint decision-making. One could say the shift has developed our partnering efforts from Connecting, to Cooperating, to Coordinating, to Collaborating⁶.

The King’s Fund⁷ describes this way of thinking about population health as a ‘population health system’ in which the four pillars are inter-connected, and action is co-ordinated across them rather than within each in isolation.

Gaining real advantage from collaboration is not easy

To gain real advantage from collaboration, something has to be achieved that could not have been achieved by any one of the organisations acting alone⁸. Although these researchers also capture what happens very frequently in practice:

The output from a collaborative arrangement is negligible, the rate of output is extremely slow, or stories of pain and hard grind are integral to successes achieved.

Our understanding of cross-boundary relationships has been clearly documented over decades of research that identify similar concerns highlighting the propensity for cross-boundary relationships to often spawn conflict because of clashes of values, working methods, identities, territories, and inter-group prejudice⁹.

Richard Vize¹⁰ recognises this varying alignment between turf and trust as relationships become more secure. Trust in turn depends on the values of the individuals and their commitment to doing what is best for patients and communities. This requires shared ownership of problems and solutions.

It is not just a question of ‘doing the right thing’ but ‘making the right things happen’^11.

Systems thinking

The current changes in statutory governance challenge organisational shifts by NHS staff into the ICS family. Systems thinking¹² adds to the theories, methods and tools we otherwise use in population health and provides new opportunities to understand and continuously test and revise our understanding of the nature of things. This includes how the NHS can address the interlinked problems of:

• struggling primary care,
• elective backlog,
• ambulance and emergency department overload, and
• delayed discharge.¹³

The ways of collaborative working depend upon our understanding and engagement with populations through agencies and communities. Strengthening trust between partner organisations and leaders, undertaking joint decision-making, and creating system-wide leadership is very much based on understanding of values and purpose. Many organisations will work across more than one level, within the new ICS leading to variation in ways of working between collaboratives, and this flexibility is an important feature of ensuring ICSs can work effectively to meet local needs.

Anna Charles¹⁴ highlights that ICSs can only be developed in each place, by each place; they must evolve and be owned locally if they are to succeed.  The strongest messages from leaders in her interviews in eight of the first ICSs was:

The importance of building collaborative relationships and trust between partner organisations and their leaders.

Hugh Alderwick’s¹⁵ systematic review highlighted a range of factors affecting how partnerships within the ICS interact, citing how, for example, relationships may move in both directions (e.g. involving staff may help create a shared vision, while having a shared vision may help with the task of engaging other partners), and may support or constrain collaboration in different contexts (e.g. national policies can help or hinder).

Deloitte¹⁶ also recognise that ICSs will differ in the approach they take towards integrated care to improve population health and are unlikely to get everything right the first time. They see the journey as more of an iterative process that will be continuously improved to address the evolving needs of the local population while incorporating new technologies and interventions.

The Kings Fund^17,  though, provides a realistic viewpoint:

No one has set ICSs up to fail. But there is a significant risk that the context into which they have been born makes it harder for the original vision of much better-integrated care to be fulfilled. The challenge is to continue to make progress to the destination even as the storms are weathered. 

At the end of the rainbow- Improving Partnership Practice

So how can we weather the storm, bring people back to the table and strengthen trust between partner organisations and leaders?

Working alongside Andi and his team at the Health Economics Unit, we have been able to highlight the importance of system’s thinking across a wide variety of stakeholders engaged in the development of partnerships within the ICS.

We have also been able to share characteristics of multi-sectoral public health partnerships which have already been empirically explored ^18,19,20, and identified how conflict and change appear to be inextricably linked²¹.

Our experiences of understanding the underlying values that can lead to conflict within a collaborative environment has led to the development of an Improving Partnership Practice tool. The tool provides a multi-dimensional concept of a partnership system that identifies issues of consensus and capacity. The tool offers the opportunity to map partnership characteristics across stakeholder beliefs and mechanisms required to support partnership development.

We recognise the potential for using this tool to support ICSs and partnership journeys and in a joint venture we are currently involved in planning the testing of an App version as a collaborative endeavour within the Health Economics Unit.

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References

1. Orlowski A (2023) Making diamonds out of sausages HSJ 31 January 2023
2. Carding N (2023) ICS has ‘strained and challenging’ relationships, review finds HSJ 15 December 2022
3. Ham C (2021) ICSs should focus on relationships as much as governance HSJ 29/6/21
4. Hill Dickinson (2022) NHS Providers within the ICS – some key considerations
5. Kings Fund (2017) Leading across the health and care system
6. Dow D (2015) Partnering Continuum Synergy Commons https://synergycommons.net/resources/the-partnering-continuum/
7. Kings Fund (2022) What is a population health approach? https://www.kingsfund.org.uk/publications/population-health-approach
8. Huxham & Vangham (2009).
9. Kings Fund (2015) Conflict and collectivism: the challenges of working across boundaries in health care https://www.kingsfund.org.uk/blog/2015/03/conflict-and-collectivism-challenges-working-across-boundaries-health-care
10. Vize R (2017) Swimming Together or Sinking Alone – Health, Care and the Art of Systems Leadership. Institute of Healthcare Management
11. Drucker P F (2007) The Essential Drucker London Routledge
12. Peters, D.H. (2014) The application of systems thinking in health: why use systems thinking?. Health Res Policy Sys12, 51 https://doi.org/10.1186/1478-4505-12-51
13. Richards L (2023) System working thrives in a culture that empowers staff to improve care HSJ 16 February 2023
14. Charles A (2018) ‘Moving at the speed of trust’ – the journey to integrated care systems https://www.kingsfund.org.uk/blog/2018/09/moving-speed-trust-journey-integrated-care-system
15. Alderwick et al 2021 – The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: a systematic review of reviews https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-10630-1
16. Deloitte (2021) Integrated Care Systems – looking back and thinking ahead https://blogs.deloitte.co.uk/health/2021/02/integrated-care-systems-looking-back-and-thinking-ahead.html
17. Kings Fund (2022) The first days of statutory integrated care systems: born into a storm https://www.kingsfund.org.uk/publications/first-days-statutory-integrated-care-system
18. Watson, J., Speller, V., Markwell, S. & Platt, S. (2000) The Verona Benchmark – applying evidence to improve the quality of partnership. Promotion & Education. VII. (2) 16-23.
19. Markwell, S. & Speller, V. (2001) ‘Partnership Working and Interprofessional Collaboration’, In Scriven, A. & Orme, J. (eds.) Health Promotion Professional Perspectives. Basingstoke: The Open University, Palgrave
20. Markwell, S; Watson, J; Speller, V; Platt, S and Younger, T. (2003) The Working Partnership London: Health Development Agency
21. Markwell, S. (1998) ‘Exploration of conflict theory as it relates to healthy alliances’, In Scriven, A. (ed.) Alliances in Health Promotion: Theory and Practice. Basingstoke: Macmillan

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Further information

If you would like to find out more about how the Health Economics Unit can support you with Population Health Management, Allocative Efficiency or applying the STAR approach please just get in touch.

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About the author

Sally Markwell is a senior lecturer within the Oxford School of Nursing and Midwifery (Oxford Brookes University).

Sally provides an eclectic experience of boundary spanning through collaborative enterprise that is informed through clinical roles within the NHS and subsequent coordination of population health management within local government. Her collaborative intuition and expertise also draws upon two decades of voluntary experience undertaking research and coordination of health education within Romanian communities and support for peace activists within former Yugoslavia.

Sally is currently collaborating with the Health Economics Unit to validate a tool to improve partnership practice within ICSs.