Competing demands and incentives
INTRODUCTION
As leaders drive forward the challenging task of redesigning sustainable services, in the course of this programme it became clear that complex ethical and economic tensions about where, when, and how resources are best allocated had frequently been encountered.
What is the reality? The challenges being felt by local systems
Individuals engaged through this programme referred to the fact that being a provider trust executive director and also involved in leading at partnership level introduces tensions that are not always easy to reconcile.
Directors of organisations (bodies corporate such as ICBs and provider trusts/FTs) have legal duties to act in the best interests of that organisation. Place-based partnerships are not organisations in law and so directors of provider trusts who are also part of a partnership leadership team would always retain their duty to their own trust. However, decision-making at partnership level should reflect the agreed intentions of the partner organisations’ boards, with reference back to those boards should decisions be likely to impact the provider organisation adversely, and so insurmountable conflicts of interest or loyalty should rarely arise.
There are genuine tensions to resolve between partners when making decisions that affect different organisations, and indeed patients, within any integrated care system or partnership – and so building trust and ensuring alignment of purpose is critical to ensure partners can have open, honest and at times challenging conversations. In the current context, some leaders said that at times they have little choice but to focus leadership and management bandwidth on the challenges they face that day, with little time or resource to creatively develop models of care and ways of working for the long-term.
Shared learnings on practical tools and approaches
The following learnings have been drawn together based on the engagement and input into this programme of work.
- A shared evidence base indicating where outcomes could be improved, and by how much, supports partners to focus on changes that can make the biggest difference for patients and service users, operationally and financially (see section on ‘starting with outcomes’).
- Programmes of this kind need to be realistically resourced – both in terms of operational management capacity and senior leadership involvement. Successful place-based integration requires significant input, with – as a rough guide – a 0.5 full time equivalent commitment at senior director level and dedicated resource among service managers running those services. It is essential to regularly check in with partners on system priorities. Establish each partner’s key change priorities and, for example, the top three priorities for the system and review these on a regular basis.
- Strong leadership is required to broker agreement and facilitate sensible prioritisation decisions – that includes taking decisions about sequencing of change initiatives through the life of the programme.
- The systems that have progressed most quickly have been able to create the space (operationally and financially) to do some transformational work that can support longer-term sustainability, while maintaining a focus on operational management. Balancing the demands of short-term operational imperatives and long-term change requires a solid structure, if progress is to be achieved on both. Consider a twin-track approach, where each have their own allocation of resource, project management, and leadership. Priorities within each group are agreed by asking “what does the system need to achieve in the short-term and in the long-term. And what does the organisation need to achieve in the short-term and in the long-term?” Avoid running short-term and long-term programmes in isolation – they can be designed to support each other. For example, responding to short-term pressure can be achieved in a way that sets the foundations of behaviours or ways of working to achieve the long-term vision. Similarly, the long-term programme can be designed in a way that delivers tangible support to operational teams as soon as possible.
- System leaders know that balancing these competing demands and incentives is not straightforward. Compromise is often required in partnership working.
- Set out a plan for discussing and resolving disputes early – there will be some. The plan can also provide an opportunity for partners to revisit priorities, maintaining alignment on the short- and long-term.
- Consider independent facilitation for dispute resolution – it is unrealistic to expect any single leader within the system to be perceived as having a neutral view across health and care.
- Recognising challenges will arise can support navigating them – assuming good faith among partners and an understanding of each organisation’s different accountabilities and incentives. At the same time, keep the original vision and system benefit at the forefront of the conversation.
- Invest time and effort in the development of a coherent strategic vision for the system, that gains the active support and genuine commitment of the leadership teams of all the constituent organisations. ‘Go slow in order to go fast’ - take the time to think through the way in which decisions will be made. If the process is undertaken in this way, when systems face challenging situations, as inevitably they will, they can be tackled against a backdrop of trust, governance, and accountability, which supports the best decision possible to be made.
“We need a way to stay friends and colleagues but fix these issues. We need the space to have these conversations frequently and openly. That requires depth of relationship and trust”
Chief executive, NHS Trust
- Work through where resources are required for new models of delivery or initiatives rigorously. Establish where the funding will come from, and which budgets accrue the benefits of the transformation.
- Reallocation of funding may be required between partners. Retain the focus on the outcome required and be prepared to think flexibly about routes to achieve this. As an example, where shared funding or pooled budgets are the goal, then perhaps a Section 75 route can support.
- A dedicated finance lead for the change programme – who understands the aspirations, the operational changes, and has dedicated time to input into the programme – can add real value. Their perspective can help with foregrounding the resource allocation tensions.
- A system benefits/system resources group of finance and operational colleagues should be set up to explore and understand this landscape in detail, acting as an advisory group to system leaders.
We hope that this publication will not be the end of the programme, but the beginning of a conversation. A series of events will be available to attend to explore the themes in greater detail and share experiences.
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