Dr Axel Kaehne is Director of Evaluation and Policy Analysis at Edge Hill University Medical School, and President of the European Health Management Association (EHMA). He is also Editor in Chief of the Journal of Integrated Care (Emerald) with a particular interest in multiagency work, service integration and partnerships in health services.
As the NHS is still fighting a dangerous battle with the COVID pandemic, it is facing one of its biggest challenges in a generation: how to deal with more than 5mio patients currently on waiting lists for hospital appointments. On top of this gargantuan task, politicians have decided to introduce significant changes to the way in which health services are organised and how they deliver care to patients in England. The time to do this couldn’t have been more inauspicious but the imminent changes to primary care networks were a legacy of the ill thought out reforms of health and social care in 2012/2013.
The new model, which is based on integrated care systems (ICSs), has two important features. First, much of the details of how ICSs are supposed to work is left to regional policy makers and managers. On the other hand, there is scant evidence on what works in bringing health and social care together with the wider primary care networks. Despite the poor evidence base, the language of integration has enormous political support and sounds intuitively appealing. In effect it means that healthcare leaders, managers and clinicians have to make things work by moving slowly into unchartered territory, trialing solutions and assessing their effectiveness as they go along. This puts significant pressure on everyone’s ability in the NHS to adapt quickly to changes, to critically review and revise.
Whilst the wider NHS has a history of organisational changes, it has not built up an arsenal of implementation knowledge for wholesale transformations. The New Care Model and Vanguard programme which took place between 2015 and 2019 was supposed to get clinicians adopting continuous change as a way of work in clinical and management practice, improving the adaptability to, and adoption of, innovations in the health and care system. The programme cost the tax payer about £330m but there is hardly anybody who remembers what it was about, what we have learned from it, or how its lessons could help us now in the current round of organisational changes. Whilst being pushed through ever new rounds of system change, the NHS as a system is notoriously poor at learning from previous policy rounds.
As central support for the present changes is likely to be limited, managers and clinicians face the real possibility of having to figure out for themselves how to bring about the new integrated care systems whilst meeting the requirements and implicit ambitions which always come with organisational changes: to improve patient care, to save costs and to increase access to care for populations currently underserved by health services. In essence, to make things better for patients for less money.
Two broad aspects are likely to cause particular headaches for ICS leaders in my opinion. First, ICSs will need to figure out a way to build patient care into everything they do. Second, ICSs will need to increase their skills and knowledge about implementing service changes within a very short period of time. Both patient care and implementation skills are a critical factor in safeguarding existing best practice whilst adopting innovative new practice. And of course, ideally, patient involvement and implementing new practices should go hand in hand. Over the last years, many managers and clinical leaders have often become implementation scientists against their will, but ICSs will need to put in place a much more systematic approach to shared learning across several ICSs if we want to move from ad hoc local solutions to embedding change in our health system.
Making patient care quality improvement the central pillar of system change is easier said than done. Of course, we have population health management approaches which aim to provide insights into health inequalities and guide us in (re-)allocating resources to the patients who need them most. This data driven model is to be applauded but will only be one side of the coin. The other side is to involve patients in a meaningful way right from the start in designing and implementing changes to frontline services.
Over the last 20 years we have built up an impressive arsenal of tools to involve patients, ranging from patient consultations to genuinely coproducing services with patients. Yet the jury is still out on whether or not patient voices can make an impact at organisational or system level and how to facilitate their meaningful involvement. The NHS is still, for better or worse, a top down hierarchical organisation, dominated by an old fashioned pecking order of professional interests which, too often, fail to listen to their patients.
There is no lack of aspiration amongst everyone involved. The question is how. Our recent Special Issue of the Journal of Integrated Care (Emerald) on Patient Centred Care and Care integration presents a raft of initiatives from across the globe to tackle these deep seated problem which are not unique to NHS Trusts in England. Learning from other healthcare systems will provide us with a key resource to place patients are the heart of emerging integrated care systems.
The second aspect mentioned above however relates to the capacity for change, our ability to drive changes and knowledge about the tools and instruments to implement change as a continuous feature of healthcare services. Integrated care systems will have to become experts in implementation science. This is a daunting task. The issue is not simply our lack of empirical evidence about implementation techniques in healthcare services. There is no lack of ever more complicated implementation frameworks.
For all the sophisticated implementation science that academics have generated over the last 15 years, there is little in terms of practical steps that strategic and frontline staff can take from the shelf and put to use instantly. The lack of clear guidance on how to translate implementation science into practical steps in a health service setting became clear to me recently when I, with a Dutch colleague, invited academic colleagues from across the world to write a chapter on integrated care with managers in mind. The task was to write for managers, producing a text that would assist them in implementing integrated care solutions in finance, digital technology, leadership and others.
Whilst everyone eventually rose to the challenge (and you can see the results here), it is probably fair to say that authors initially struggled with the practical focus of the task. It is one thing to summarise the empirical research evidence on integrated care yet another to translate that into clear and robust guidance on what managers should do on a Monday morning when they come into the office. The lesson here is that we are still a long way from providing practical useful guidance to managers and clinical leaders who face difficult decisions as new governance and service delivery models, such as integrated care systems, are emerging. Academics and researchers alike need to get better at providing advice and support for implementation and evaluation of change programmes in the NHS and wider care systems. Otherwise the next system transformation in the NHS will prove as difficult as the last.