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Historical ways of working and behaviours

Overcoming barriers to delivery
Barriers to delivery



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

man adjusting

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.

“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

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