A core principle underpinning this toolkit – informed by reference sites’ experiences – is that efforts to integrate care at place have been most successful where the changes measurably result in better care being delivered for people.
Stakeholders engaged through this programme agreed that any work carried out to improve services - through place-based partnerships or otherwise - must result in a measurable improvement in outcomes for people and/or staff.
“This has to be about our population’s health in five years’ time, or this vehicle of integration has not been worth it.”
Acute NHS Trust CEO
The toolkit is designed to reflect this focus on outcomes. It is presented in three sections – some of the elements and steps required to start and focus on outcomes; some of the common barriers that leaders engaged through the programme felt needed to be overcome to make integration work successfully; and the crucial role of culture and leadership that underpins all of this.
Each section of the toolkit explores the range of challenges that those engaged through this programme said they have encountered. Sections then outline some of the ways in which these have been addressed in practical terms, followed by some case studies from reference sites. The intention is that by describing experiences of making integration work on the ground, other systems can learn to pre-emptively address some of the issues that can slow or derail implementation.
More detail on the content of the three sections
As described through the introduction, making integration a reality is highly complex and will not look the same in every place. While the toolkit is not designed to be comprehensive in its breadth or depth, individuals and systems engaged through this programme reflected that focussing on these areas can contribute to delivering better care and improved outcomes for people through new and optimised place-level services.
Starting with outcomes.
In practical terms, the toolkit explores the elements that need to be in place and the steps required to:
- Start with outcomes
- Ensure clarity on what must be achieved
- Keep measurable outcomes at the heart of the design of place-based partnerships.
Overcoming common barriers to delivery.
The systems involved shared some barriers they encountered delivering improved services with better outcomes and the process of making integration a reality. These are grouped into workforce pressures; competing demands and incentives; navigating governance and moving beyond a focus on structures; lack of joined up data and insight at place; and historical ways of working and behaviours.
Culture and Leadership
Leadership skills and associated culture, behaviours, and norms are critical to the success of integration at place. In creating the toolkit, leaders reflected on the value of their shared commitment and ambition in overcoming the common barriers. They emphasised that the culture within organisations and on the frontline can make or break joint working and delivery of improved outcomes.
An 'inside-out' approach
Those engaged through this programme reflected that traditionally, systems often begin the process of integration at place by focusing on established solutions or by adopting new service models from elsewhere.
Measuring the outcomes is seen as a challenge to be undertaken once the system is running smoothly at a later stage. In taking this ‘outside-in’ approach and implementing an existing solution into a new system, the experience was of several complex obstacles or barriers to overcome, which then proved difficult to resolve.
As the barriers impede achievement of the anticipated benefits, leaders attempt to compensate and overcome them by driving the solution even harder. While this may work in the short-term, the symptom-fix will not be sustainable, since the root cause is the lack of a clear, outcomes-based ambition as the starting point.
Conversely, it was found that where place-based approaches are making progress and gaining momentum, partner organisations have all started with the measurable outcomes to be achieved. This generates a strength of alignment, culture, leadership approach and ways of working with which the system can tackle and overcome any barriers to change that do emerge.
Furthermore, it was found that the systems making most progress were regularly returning the focus to the outcomes. To apply continuous improvement in this context, these systems revisit the measurable outcomes on a regular basis, reviewing key measures as part of day-to-day delivery and governance. This allows service delivery to be iterated over time and supports a systematic approach to tackling or mitigating barriers.
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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