Integrated Care Systems (ICS) SOS DIY?
2 May 2022
Written by Keith Burnett, guest blogger and Interim who specialises in health and social care integration
1. History Repeating
Back at the turn of the century, Professor David Hunter pointed out that the problem with most NHS health system reorganisations was that just as they were starting to bed in, right at the stage where benefits might actually be realised, a fresh, destabilising reorganisation landed – generating what he memorably entitled redisorganisation. It’s not a syndrome unique to the UK, of course, but arguably we are truly world-beating when it comes to starting off radical change… if not always the best at following it through to fruition. The ICS change programmes sweeping England at present are not the first such attempt at change, and equally certainly won’t be the last, but locating the experience in the wider sweep of history can be helpful in navigating today’s challenges and opportunities.
Health and social care integration is a gradual process, taking place over years and decades, and progress doesn’t drive in a straight line. “Two steps forward, one step back” is a dynamic everyone involved in the system for long enough experiences, as a brief look back to a decade ago illustrates. By the time they were broken up, the old Primary Care Trusts were just starting to show what a positive difference they could make, combining the population outcomes focus of public health with, in many cases, social care leaders joining their top teams. That progress was temporarily brought to a halt by an ideological fixation which insisted, in a nutshell, that trained managers were no good at managing and clinicians should be drawn away from patient care to do it instead. To see how that worked out, a glance at the average CCG’s early experiences is sufficiently informative. So, yes, we have been here before, and we all know as a result that immunising public sector organisms against muddled thinking can take more than one jab. What we are going through now is, at the very least, an opportunity to learn those lessons afresh.
2. Dance Like No-one’s Watching
This is not a drill, as your local Integrated Care Partnership’s chair will be only too happy to tell you. But it’s not necessarily an emergency either. July 2022 may seem a rapidly looming target date, yet it’s one which has already been postponed, and the criteria for passing the test are tangibly relaxing as the date approaches. In practice, as long as a Chair and key board appointments have been found, neither Government nor its arms-length bodies seem inclined to exert much further pressure at present.
A degree of scepticism is understandable given the diversion of the ostensible Social Care Levy to back-fill NHS funding gaps, and with an election not far around the corner the more ‘relatable’ aspects of NHS planning (hospital waiting lists, typically) are likely to steal the limelight. External scrutiny can therefore reasonably be expected to be limited in scope and import for the next two years. Funding is similarly unlikely to expand or investment restrictions ease – but on the other hand, two years is plenty of time to experiment, try new ways of working, test the readiness for community-centred service design in real-world conditions and then go in to the next reform process with a much richer picture of what works, and what doesn’t.
3. I Never Promised You A Rose Garden
This is not the final stage of the long struggle to combine health and social care, or anything like it. Most of us will be able to observe the process continuing well into our respective retirements – as long as we keep the pot simmering for now. That realisation has obvious consequences for communications, both internal and external, where the old adage “under-promise, over deliver” is once again valuable. Even modest progress towards better co-production would be valuable, and if most ICS programmes identify at least one Place in which prominent examples of community-centred design leap to mind next time the system is up for reform, we will none of us regret using the time well.
4. Karma Chameleon
The Culture Club reference is deliberate, because moving away from the purchaser/provider model to Place-led design entails a huge culture change. Just as obviously, that change can’t be delivered through a top-down, command-and-control approach, although learned behaviour will doubtless make that the starting point in some cases. Fortunately, there’s always another chance. Talking of karma, NHS reorganisations generally get what they deserve, which is to be reorganised again. How this period of institutional destiny is lived will determine what sort of animal the ICS comes back as in the next life.
5. A Design For Life
Commissioning isn’t dead – just pining for the fjords. In reality, many hard-working professionals, even some formally styled as commissioners, have been required by policy to engage largely in purchasing and procurement for years. That’s not their fault, but the natural scepticism which results is a barrier which change efforts need to overcome in order to be effective. A vital part of the solution, in practical terms, is to make commissioning meetings and conversations more interesting, engaging and palpably useful. Literally no-one goes to their grave wishing they’d spent more time drafting terms of reference, for example, but moving dull admin tasks to email/Teams can free time to get into the detail of process-mapping from the citizen’s perspective, which is always a revelation. The work doesn’t have to be directed by the usual suspects, either; there’s no rule that says the chair has to be the most senior person in the room, so if someone from a non-CCG background has the time, energy and facilitative skills, why not let them drive the activity? Remembering that this is in many respects a rehearsal for major system reform rather than the real thing is liberating; bearing in mind that everything we learn now can be scaled up and re-used later makes the experience valuable.
6. People Hold On
Some ICS boards might look an awful lot like CCGs, but that’s hardly surprising; many CCGs closely resembled PCTs for their first few years too. How far local leaders manage the transition away from command-and-control towards genuine partnership working will nevertheless have a major bearing upon readiness for the next reorganisation. Visible success is more likely if the focus is on the ICP, rather than the ICB, because true partnership working has more to offer to new ways of working than a rebranded board, but either way lessons can be learned, and the opportunity to use them will come sooner than we might imagine; just look back at the Covid pandemic, and two years doesn’t seem that long at all.
7. Get This Party Started
The branding may suggest that this is an opportunity to advance health and social care integration, and indeed it may eventuallybecome that if we take it, but with political attention directed largely at the NHS (when anyone’s looking at all) it’s perhaps as well to remember that although social care folk haven’t been explicitly invited to the party, we can invite ourselves. To make sense of all the talk about locally-focused co-production, the expertise of professionals trained in just that art has a lot to offer. Colleagues may just require a little moral support to turn up without fear of being seen as gate-crashers.
8. Rip It Up And Start Again
As any old soldier in the public sector will tell you, the only constant is change. Perhaps we shouldn’t fear that too much. The very existence of Britain’s welfare system(s) is the result of thinking which seemed decidedly radical at the time, and a willingness to throw out old assumptions when they didn’t work any more. If we weren’t ready to start anew in the pursuit of social justice, we’d all still have a pot on the mantelpiece to collect shillings in case a doctor had to call. Why, after all, should this attempt at change be exempt?
A hard reality is that when change efforts are not fully thought-through, a degree of failure is inevitable. The Agile mantra has wisdom to offer here, in the invitation to fail fast – and learn the lessons for next time. There has been plenty enough ‘creative destruction’ already, and soon the dialogue will turn to finding the best ways to rebuild; if your patch has learned positive lessons and can share them in two years’ time, there’s a fair chance you’ll be in the vanguard.
9. Confide In Me
Major organisational change can feel dramatic, even traumatic, and after a decade’s partial peace some current system leaders might be experiencing the upheaval of office moves, rebranding, and reapplying for their jobs for the first time. Remembering what motivates us as human beings is central to surviving the experience and being ready to apply the learning when the time is ripe.
NHS reorganisation really isn’t the end of the world, but some behaviours will drift into darker territory nevertheless. When the pressure is on, maladaptive coping mechanisms range from inoperable strategies and anaesthetically dull meetings, at the relatively benign end of the scale, to toxic management methods at the other extreme. There is a limit to how much of this it is wise, or useful, to put yourself through. In some of these circumstances it can be worth attempting supportive challenge, but in others, the sagest approach is protect yourself (and those you manage) and sustain learning and enthusiasm for a better day. Distinguishing between supportable and unsupportable cultures is next to impossible when the only points of reference are other people acting out that culture, so it pays to keep in touch with critical friends outside the tent. There are plenty of us (me included) – you only have to ask – and the occasional confidential conversation might do a lot more than nurture mental health; it could even be career enhancing. Profound change is difficult, and we’ll need you… probably sooner rather than later.
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