System-wide working is no longer an ambition but a legal duty entrusted to Integrated Care Boards, with clear requirements to deliver the four aims of healthcare: increasing quality of care, improving health and wellbeing for all, sustainable use of resources, and delivering social value.
Achieving these goals in practice requires more than simply collaborating or strategically aligning. It needs genuinely integrated planning for populations and pathways to the operational workforce and capacity level. This means connecting the outcomes we seek with the drivers that will enable that change to happen, challenging organisational silos and traditional ways of working to develop innovative, sustainable ways to deliver what is needed on the ground.
NHS leaders are already recognising the shortcomings in the traditional, top-down, target-based approach to planning. Instead, there’s a recognition that we need to be more transparent about what we're seeking to change and actively engage with stakeholders across systems, both to identify priorities based on population needs and, crucially, work out what changes need to be made to achieve better outcomes and value for our communities.
Understanding the operational impact of change is essential for success. For example, a system wanting to improve mental health among adults and young people post-COVID could identify a set of ambitions such as changing a pathway, improving diagnosis or providing access to support services within the community. Truly integrated planning connects the drivers of change to the outcomes sought. What changes are needed? What would the impact be on A&E, diagnostic services or outpatient wards? How would we need to change the workforce to respond? What change would be required to budgets, supply chains and use of a system's estate to effect this change? Only then can systems realistically assess, hold to account and implement the changes required to achieve this goal. Many operational plans need to be dynamic and responsive to the drivers that managers see every day, and therefore be a tool to mitigate and manage risk.
Clinical and community engagement
Clinicians working for population groups can bridge the gap between strategic ambition and operational delivery and should therefore be at heart of integrated strategic and operational planning. Bringing together multidisciplinary teams across primary, acute and community care, and the voluntary and private sectors enables systems to develop a deep, system-wide understanding of effective ways to deliver change on the ground, whether that’s how the workforce is deployed, what technology can be applied or how we can deliver differently without costing more money.
Investing in clinical and community engagement enables systems to innovate with key resource owners including citizens and employers in the room, sharing their input to find holistic, integrated solutions to the challenges we face.
Risk and resilience
Recent experience has demonstrated all too clearly the disruptive impact of external factors outside our control. In the last year alone we've experienced new infections, workforce issues, rising costs and war in Europe. In these turbulent times, systems must build resilience into plans which allow them to flex their approach according to changes in circumstances, without having to grind to a stop or restart plans from scratch. This requires a strong handle on the risks we all face, with appropriate focus on monitoring, mitigating and responding to issues as needed, creating a dynamic planning environment.
This becomes much easier to do if we build clear, evidenced assumptions into our plans based on best practice and agreed impact. In our earlier mental health example, to improve access to services at community level, our integrated plan would include an inbuilt assumption about workforce requirements based on the expected number of clients coming in. If those assumptions change, such as a change in the acuity of patients, a major infection outbreak, or other ‘what if’ scenarios, we would be able to model the impact of those changes and adapt the approach accordingly in real time. This means a more agile, responsive service, as well as a more accurate way of determining outcomes.
Governance has a critical role to play here. Multidisciplinary, connected governance across the layers of a system for a given population enables effective decision-making at primary care, place, area and regional level across health and social care. This connectedness, with appropriate safeguards in place, makes it possible to be responsive without getting caught up in process. The COVID-19 vaccination programme allowed us to see the benefits of truly integrated strategic and operational planning in action. The circumstances were, however, equally exceptional, and the programme's success was due in part to a sense of 'we're all in it together' and a willingness among people and organisations to cede authority to achieve a single objective. But it demonstrates just what can be achieved when we pool resources and expertise.
The future challenges for health and social care are different now but no less daunting than they were at the start of the pandemic. With ICBs now established, systems across England are looking at how to address their population's greatest health challenges and work in a more integrated way with system partners to achieve their ambitions. Both the NHS and local government have a track record of being generous in sharing information and learning in the drive to improve services for their communities. So as ICBs look to embark on more ambitious integrated plans, those of us working across regions should also step up to accelerate that learning, how to share assumptions, capture evidence, decisions and impact. Connecting plans for operational team resilience with strategic population goals is essential to help deliver a more sustainable, resilient and adaptable health and care service more able to weather any oncoming storm.
This blog was originally written for Healthcare Leader and can be accessed here.
