Getting integration to work: is it time to stop throwing policy at the problem?

Culture eats strategy for breakfast. Clichés persist for a reason: there’s truth in them. For at least the last 25 years, the NHS has aspired to create better integration across a range of boundaries – primary and secondary care, physical and mental health, health and social care – all with the aims of creating a seamless experience for patients and service users and a more efficient use of resources. “Care closer to home” and “person-centred care” have been mantras for years.

So much for the rhetoric. What’s the reality?

Last July ushered in new era for integration, when 42 integrated care systems formally assumed legal responsibility for planning local services and health spending. Within these reforms, emphasis has been placed on place-based partnerships – NHS organisation, local authorities, voluntary and community sector organisations, and broader local communities – to work together locally and do much of the heavy lifting of improving care and collaboration. So what would make us more optimistic about the success of this approach to integration compared to its many predecessors?

Working cultures need to change

Between 2021 and 2022 we held a series of roundtables with those using services and leading delivery locally to explore this question. Today we publish a briefing setting out our findings from those discussions and making a number of recommendations for local leaders.

While much of the discussion centred on where policy isn’t working – whether in clarifying complicated governance structures, ensuring the right incentives for collaboration, or securing enough resources so that services can work well together – some of the knottiest issues remain areas that policy can’t easily touch.

Despite at least 25 years of structural reform, integration hasn’t happened because working cultures in the NHS and social care haven’t changed to support collaboration. Integration has too often felt removed from the day job of those working in services, and from patients and services users who would gain so much from seeing that more joined-up care delivery actually happens.

Integration is not the objective for its own sake – it is an approach used to streamline services for people accessing them, to improve outcomes and help keep people healthy and well. Integration only happens if people do something different as part of their day-to-day work – structural shifts and changes to organisational diagrams alone will never drive change.

And “culture” is not some nebulous external factor; it is intrinsic to organisations and systems. If culture is “the way we do things round here” then the only way we will change the culture is through the daily actions and works of teams on the ground.

For change to happen, and for people using and working in services to see the benefits of integration, an “integration-in-all-policies” mindset is needed to drive change in day-to-day clinical and managerial practice.

Key questions for leaders

ICS and place-based leaders should be holding at the forefront of their minds the question of “what will be different on a Monday morning”? First and foremost, how will the experiences of people who use services be different and better? How will the way in which GPs and consultants interact with each other change? What will be different for the district nurse or for the domiciliary care worker? What different conversations will chief executives be having, with whom, and what will happen as a result? How will success be measured? And how will these changes be achieved within the resources available?

These questions, and others like them, make integration more visible and tangible for front-line teams, a daily part of the way they work and think about their role. While often the focus of policy, they are questions which can never be answered by a white paper, legislation or policy reform alone.

Addressing these questions may also lead to a rebalancing of capacity across the system. Not just operational capacity, but management capacity. The parts of the system being asked to undergo the most change at the moment, in primary and community services, are probably the least well resourced to do so. It’s hard enough to keep the wheels on the road in primary care, let alone to dismantle and rebuild the vehicle while its engines are failing.

And they may lead to better partnerships beyond the NHS – not only with social care commissioners and providers, but with the voluntary and independent sectors, with other organisations within a place who also impact on communities and with patients and the public themselves.

Handing over power and agency

Ultimately, integration may be advanced through a series of small improvements to ways of working rather than striving to build the “perfect system” on paper through continuous reform. But improving the way teams work together in places requires handing over power and agency to places directly. We saw this happen during peaks of the pandemic, and it needs to be reignited in the face of the current challenges facing health and care. And local leaders need to take that agency and run with it – to make “look out, not up” real at last.

But if we continue to spout the rhetoric of “person-centred care” while in practice measuring success through an institutional lens, and a bed-focused one at that, then chances are that the old cultures will be perpetuated, and in five, 10, 15 years’ time we’ll be reading yet more white papers which paint utopian visions never to be achieved, and strategy will continue to feature prominently on the breakfast menu.