The argument for systems to be at the centre of the NHS and social care in future stems from changes in demography and the burden of disease. The population of England is growing and ageing; premature deaths from cardiovascular diseases and cancers are falling; and the share of the burden of disease resulting from morbidity is increasing. Multimorbidity and frailty are both on the rise and risk factors like overweight and obesity are storing up problems for the future. Rising to these challenges requires a systems response.
In the case of health and social care, integrated care systems are needed to ensure people experience joined up and not fragmented services, especially when they are in contact with different health and social care staff. Much the same applies to prevention where the NHS must work with local authorities and other agencies to tackle the wider determinants of health and wellbeing in population health systems.
Glimpses of the future can be found in places that understand these drivers of change and have put in place systems focused on the needs of populations and places. The Canterbury District Health Board in New Zealand is a well-known example of an integrated health and social care system that has delivered impressive results for its population. For over a decade, Canterbury has worked towards becoming one system with one budget, moderating increasing demand for hospital care by investing in joined up services in the community.
Closer to home, The Healthier Wigan Partnership has shown what is possible when a local authority is willing to think and act differently with other partners in a population health systems. The focus here is on asset-based community development in which the council works with people and communities to use resources more effectively. The results can be seen in improved health outcomes and an investment in community groups that have found more innovative ways of meeting people’s needs than those provided by the council.
The commitment in the NHS long term plan to establish integrated care systems across England by 2021 indicates that systems have entered the mainstream of health policy. These systems are being overlaid on NHS organisations with statutory duties and accountabilities and in a context of almost thirty years of NHS reform being driven by a belief in competition rather than collaboration. Progress depends on these organisations being willing to work in partnership and on regulators changing their behaviours to support system working.
Research by The King’s Fund into the early experience of integrated care systems shows how local government and NHS leaders are working together in some areas to create the conditions for success. Different accountabilities between local government and the NHS create challenges but are being overcome where leaders see benefits in finding common cause around their populations. Time spent developing shared visions is often valuable in this process and Health and Wellbeing Boards have been a means of enabling population health to rise up the agenda.
Working in partnership is facilitated when there is frequent personal contact between leaders to build understanding and trust, a commitment to work together for the longer term, and an open book approach to sharing financial and other information. Also important is the ability to surface and resolve conflicts, rather than letting them fester, and to behave altruistically towards partners. Acting on these insights requires leaders to work and behave differently, using influence and soft power rather than relying on hierarchical authority.
System leadership takes time to develop and progress occurs at the speed of trust. The legacy of competitive behaviours in the NHS presents an obvious challenge and requires a serious and sustained investment of time in relationship building. A clear message from early adopters of integrated care systems is that relationships matter more than structures both among organisational leaders and staff delivering care to patients and service users.
Peter Senge and colleagues have argued that the challenges facing our societies can only be tackled by systems and that we are at the dawn of system leadership. They note that ‘Transforming systems is ultimately about transforming relationships among people who shape those systems. Many otherwise well-intentioned efforts fail because their leaders are unable and unwilling to embrace this simple truth’. This advice is ignored at our peril.