Health and care systems have developed and changed over decades. The course of innovation and improvement has brought huge gains in service capabilities, but has also brought complexity and a history of ingrained cultures, habits, and expectations. There are hundreds of examples of this, many of which were shared as part of this programme:
“It has never been the role of this organisation to carry that risk.”
“I’m a community nurse / social worker / therapist / GP, it’s not my job to do that.”
“Our arrangements with this provider have always been this way, that’s just how the contracts work.”
Deep rooted histories, whether that is between organisational cultures and leadership styles, or the way that different professions work with each other day to day on the frontline (informed by clinical regulations and licenses), require careful consideration when delivering place-based integrated services.
“NHS organisations and local authorities have different governance structures, different accountability, and different behaviours. We need to understand politics, they need to understand clinicians.”
Chief finance officer, NHS Acute Trust
What is the reality? The challenges being felt by local systems
- Often, organisations’ patient and service user flows are not neatly coterminous with place.
- Local health and care organisations view situations from different perspectives and operate with different drivers and constraints. For example, health teams operate within a context of national targets and a centrally led architecture, via an annual planning cycle. Local authorities, alternatively, are politically-led and accountable through local elections, are legally not able to over-spend on a budget, and generally operate based on medium-term financial planning.
- “Outcomes-based and person-centred” can mean subtly different things to different system partners and teams.
- Historically fragmented commissioning means that the focus can remain on traditional service interventions rather than developing service models that wrap around the needs and strengths of individuals.
- Coordinating across a broader array of public services to deliver place-based approaches can involve working with housing services and working-age welfare services (and others) and introduces further institutional interfaces where professional groups come together with different traditions, ingrained cultures, and priorities.
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.
- In this work, system leaders shared the time investment required to break through this barrier. At all levels of partnerships, teams reflected on the value of setting aside development time to listen and understand teams coming from different organisations and traditions. In successful systems, senior leaders have been able to explore their past and current drivers, pressures, and even their frustrations with system working. Frontline staff have been able to share their day-to-day experience, how it has changed, what their job now embraces, and their motivations and frustrations. This organisational development work takes time and careful facilitation, but the approach has brought a deeper level of mutual understanding and trust between historically different professions and cultures.
- Seek feedback and insight from teams about how they are feeling about the partnership and about their roles. Undertaking this exercise frequently and consistently can allow leaders to identify warning signs and intervene. The engagement of teams can be measured in terms of their understanding of the purpose, their desire and belief that they can deliver, the support they receive, their understanding of new ways of working, and their relationships with other partners at place.
- Designing change that is easy to adopt can make or break new service delivery. Consider undertaking ‘day in the life’ exercises for the teams delivering the services to generate a map of the level of change it brings from their current way of working.
- Finally, it helps to have realistic expectations of timeframes involved in embedding new services and ways of working across teams. It can take 6-12 months to fully adopt and refine new ways of working in teams.
“We should remember the impact of historical hierarchy, both within organisations and between. We have seen a real shift in culture and made big inroads to the relationship between GPs and acute clinicians, which is supporting better care and easier access for patients”
GP and Clinical Lead of Federation
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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