Solidarity in difference – the ICS conundrum
While common goals are essential for ICSs, their local differences and individual challenges must also be acknowledged and harnessed to achieve success.
As we start to prepare for the ICS Network conference in a few weeks, I have been giving some thought to what I might say to the group of leaders who will be joining us.
Just about every day we hear the name of another person appointed to chair one of the 42 integrated care systems. Already, we can be sure the chairs will be an eclectic, talented and independently-minded group of people. Whether and how they and the systems they lead and work together is critical both to the success of the current health and the future of the NHS in England.
Context for change
As I have mentioned in these blogs and written and spoken about extensively elsewhere (this is a six-minute animated version) it is useful to think of the context for change in three dimensions: top down, lateral and bottom up. Successful change often sees these three sets of drivers not just articulated, but in reasonably good balance.
What might this framework suggest in terms of the role of integrated care system (ICS) leaders?
First, ICS leaders need to work with the centre in the form of NHS England and NHS Improvement, the Department of Health and Social Care, regulators and wider government.
Second, ICS leaders need to work with each other in a spirit of robust support and challenge and with a commitment to innovation and continuous improvement.
Third, ICS leaders need to work with the constituent parts of their local systems largely comprising three parts: NHS service providers, local government and wider civil society
Already much attention is being paid to the third aspect of this. Many ICSs have been up and running – in various forms - for some time. The scale of ambition, the degree of engagement and the quality of local relationship vary from system to system. Equally, systems are working out what needs to happen at system, at place and at neighbourhood scale.
Commitment and support are crucial
It is a widely agreed aspect of the NHS that leaders spend too much time looking up to the centre and that the centre finds it very hard to resist micro-management.
But what of the other two levels? Here the cohesion and commitment of ICS leaders and the support they are given is crucial. It is a widely agreed aspect of the NHS that leaders spend too much time looking up to the centre and that the centre finds it very hard to resist micro-management. This, by the way, is a view I hear as often from people in the centre (albeit sotto voce) as from leaders on the ground.
If ICS leaders can develop a strong and shared perspective and show a willingness to fight their collective corner in the ultimate interests of improving health outcomes and – crucially – achieve some quick and tangible wins, they can wrestle some control from the centre. This would be good not just for ICSs, but for the balance of the health system as whole.
Learning from each other
Part of convincing the centre to let local leaders lead is their commitment to learning from each other. The NHS Confederation is exploring how best to offer peer-to-peer support to systems. Forty-two is good sized group to enable, on the one hand, meaningful comparison of challenges, strategies and performance. For example, this analysis published by Carnall Farrer and IPPR offers a fascinating and, for some, rather sobering insight into the degree of local integration in systems. On the other hand, it is small enough for people to develop relationships and to bond; something that is essential if meaningful support and challenge is to develop.
It is precisely the importance of letting systems evolve in different ways that should be one of the first calls made to the centre by ICS leaders.
However, the idea of developing common cause and creating a context for meaningful peer-to-peer improvement might seem to imply uniformity across the ICSs. But as I have written before – and as the reality on the ground is already showing – ICSs are going to be very different in their local institutional history, in the challenges they face, in their ambitions, in their ways of working and in the progress they are able to make. Indeed, it is precisely the importance of letting systems evolve in different ways that should be one of the first calls made to the centre by ICS leaders.
There are plenty of people who are sceptical of the ICS policy. For some it is a generalised pessimism about the scope for any restructuring to work, for others it is a more considered preference for power to lie in the hands of provider institutions. If ICSs don’t provide reasonably early evidence of impact, those who were unconvinced from the start will become emboldened.
But if ICS leaders can build both a powerful and generous collective voice, focused not on self-interest but system improvement, and create a space for robust experimentation and learning from diverse contexts and practices, they can become the leaders not only of their own systems, but of wider health and population health policy.
Matthew Taylor is chief executive of the NHS Confederation. Follow Matthew and the NHS Confederation on Twitter @FRSAMatthew @nhsconfed
