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Arden & GEM CSU > Solutions > Integrated Care Systems


Integrated Care Systems

Sustainability and Transformation Partnerships (STPs) have started the process of bringing local partners together to work collaboratively towards a shared vision which delivers the triple aim priorities of the Five Year Forward View. As a number of localities begin their journey to integrated care, the system must go beyond formal collaboration to truly shared accountability across the local health economy.

With a proven expertise in bringing together health, social care and the public to transform services, Arden & GEM CSU is able to support your journey to integrated care at each and every stage.

Developing the capabilities to deliver integrated care

The move to integrated care is complex. For this transition to work successfully, we have identified four key areas of capability that are required to support delivery. By creating the right environment, developing the right infrastructure and engaging with the wider community, health and care systems can meet their collective goal of delivering best possible health outcomes. 



System leadership and behaviours

With experience of bringing people and organisations together to work collaboratively to achieve a shared vision, our support includes:

  • Co-production events for strategy development and stakeholder ownership
  • Collaborative relationship building across services, providers and sectors
  • Organisational development to support system change
  • Exploring organisational risk appetite and scenario exercises
  • Senior recruitment and board development.

System design and governance

We have built upon our experience, in supporting local health economies to agree and develop formal integration and joint accountability, to offer:

  • Establishing inter-organisational agreements around risk sharing and Memorandum of Understandings
  • Whole system, activity and financial modelling
  • Triangulation of data underpinned by robust management and information governance arrangements 
  • Development and specialist procurement of innovative contracting models including alliances, integrator, lead provider and outcome based
  • Developing outcomes frameworks, attributable output metrics and managing system performance.

Empowered citizens and communities

We can support you to empower communities to engage in the design of healthcare provision within their local area and to help individuals to take greater responsibility for their own health through:

  • Public engagement and involvement including innovation and co-production events
  • Shared decision-making
  • Behaviour change driven through award winning social marketing and nudge tools
  • Digital enablers such as remote monitoring and self-care applications.

Reimagined care

We have proven, award-winning approaches to designing, developing, testing and delivering cost-effective care models which have been deployed across a wide customer base, including:

  • Patient pathway/service redesign
  • Population health analysis, population segmentation and risk stratification
  • Digital diagnostics and therapeutics strategies
  • Change models and tools including logic models, evaluation frameworks, rapid cycle improvement and LEAN.

Creating a roadmap for the transition to integrated care

We recognise that all systems have their own unique challenges and have designed our methodology to respond to these challenges with tailored support. Our methodology embraces three phases – Discovery, Development and Delivery – intended to ensure fledgling Integrated Care Systems move from initial shaping and strategic planning to clearly articulated transformation and implementation of a robust operating model. 

These phases can be used to support development of any of the capabilities above, or to provide a more holistic approach to bring existing ambitions and transformation programmes into alignment with new systems and organisations – creating a clear roadmap for the future.



The starting point for any system change must be an understanding of the current situation and agreement between all partners of what the future state should look like.

We have experience of providing the analysis and insight that ensures the right problem has been diagnosed and that national policy, strategy and recommendations are being utilised. We can work with you to understand your system’s current capability and identify any gaps, so our support can be tailored to your specific needs.

We have worked with a number of health economies to determine and articulate their vision for care and develop a shared set of objectives and narrative. For most STPs, an outline will already exist which we can help form into a programme. For localities needing to work on this at pace, we have successfully developed and delivered Accelerated Learning Events to achieve this.


Once the desired change has been agreed, an effective delivery programme needs to be designed to achieve the transformation.

We have acted as a critical friend for commissioners and regulators by conducting service reviews, offering programme assurance, scoping QIPP opportunities and linking those opportunities to interventions that have been proven to work in demographically matched cohorts.

We have designed award winning new care models, developed new contractual models and frameworks and produced comprehensive plans to ensure that the enablers of change, such as workforce and technology, are aligned.


Where self-implementation is not an option – whether due to capability, capacity or expertise – our thousand strong team of professionals, and network of partners, can support you to transform your strategic plan into a robust operating model.

We have a strong approach to programme management, whether delivered at a local level for a specific service redesign or at a national level for initiatives such as NHS RightCare, which will ensure your transition remains on track – reducing risk and maximising impact.

Our multi-award winning procurement and market management service is experienced in utilising our unique seven step strategic procurement process with a focus on patient, clinical and market engagement. Recent projects have integrated service provision, streamlined pathways and delivered significant savings for commissioners.

Our unique business intelligence environment provides the data, intelligence and tools to monitor delivery to forecast and mitigate risk. By bringing together local health data from our in-house business intelligence system GEMIMA with specialised services activity data hosted in the National Commissioning Data Repository (NCDR) and social care data from local authorities, we can provide STPs and ICS with a unique level of insight and intelligence across end to end care pathways to inform robust decision making and improve patient outcomes.

In addition to the examples above, we are able to support delivery and implementation across a wide range of service areas including business support and clinical support.

Continuous learning and improvement

Successfully establishing an Integrated Care System will need a culture of continuous improvement, ensuring that measuring outcomes, impact and replicability is built in from the start.

We can establish and support continuous learning approaches, at an organisational and system level, including running learning networks and adapting and adopting successful care models from other health systems.

We have a detailed and robust evaluation methodology that directly supports clients, including vanguard sites, as they redesign services, implement new models of care and deliver against their STP. The evaluation framework has been built to assist organisations throughout the cycle of change - from positively influencing the design of a programme, to improving ongoing efficiency and effectiveness, and reporting what has been achieved.

We can provide the capability to ensure that evaluation and improvement methodology is underpinned by a robust system of controls and assurance.

Why Arden & GEM

Our strong background and passion for integrated working across the social care, voluntary, community and health sectors makes us your ideal strategic partner. We can help you to build an Integrated Care System which focuses on prevention, personalised care and innovative, collaborative new models for the way that health services are provided.

We can help you to navigate barriers to change and implementation challenges. Our ability to draw on expertise from over 1,000 staff – including procurement, analytics, organisational development, financial modelling and IT systems specialists – enables us to anticipate where barriers might be met and to quickly develop practical action plans, which can overcome them

We have established relationships with a dynamic network of partners, including those from the private, voluntary and education sectors, enabling us to specifically respond to your challenges and fast-track development of best practice.

With an NHS pedigree and a portfolio of work underpinned by rigorous, industry leading governance frameworks and quality standards, we are uniquely placed to support your transformation journey.

For more information on how we can support your journey to integrated care, contact Wendy Lane on wendy.lane@ardengemcsu.nhs.uk.


By using the HARMs audit as part of the prescribing incentive scheme, the CCG has raised awareness of the role of safer prescribing and polypharmacy in reducing hospital admissions.
Assistant Clinical Chair, South Warwickshire CCG

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