The Darzi Report highlighted tensions between system leaders and providers as one of the challenges facing healthcare, citing duplication of roles and inconsistency in key areas among aspects that need to be addressed. This lack of clarity is no great surprise – Integrated Care Boards (ICBs) have existed for just 18 months and represent a significant shift in how health and care organisations collaborate. As David Buck et al state in a recent report by The King’s Fund, Public health and population health: Leading together, ‘the cultural and structural changes required to fully realise the opportunity of ICSs clearly need time to bed in’. Resources are stretched, demands are high and the new 10-year plan for the NHS will likely prompt further changes. So, what are the key elements leadership teams need to prioritise to strengthen existing initiatives and enable future priorities to succeed?
Fixing the foundations
It’s worth stating that tension in a relationship is not inherently bad, though it can become so. You need a certain amount of tension to create energy for change and to encourage appropriate challenge, including between system leaders and providers. Being empowered to ‘speak truth to power’ is crucial if we are to continuously improve. But fostering an environment of constructive tension relies on trust which is not a switch you can flick. Trust has to be built. Doing so successfully provides the strongest foundation for successful working relationships, particularly when under pressure or managing competing priorities.
Trust is best developed by working through challenges together, making mistakes and collaborating in fixing them. System leaders are in a challenging position, managing system versus organisational priorities with limited time to invest in developing leadership skills beyond their established strengths. But we are seeing positive results from our work to support mindset shifts of these leadership teams and realign how board members make decisions.
In our experience, when asking board members who their ‘home team’ is, i.e. where they feel most aligned, they will typically align themselves to their function, whether that’s HR, finance, medicine, or indeed the organisation they represent. For ICBs to work more effectively, board members need to see their executive team as their home team and adopt a ‘we’re all in it together’ approach. Adopting this multidisciplinary, cross-organisational approach at executive team level underpins the need for making decisions that may not always be in a particular organisation’s favour but does support the wider system, helping to reduce provider/ICB tensions.
Shared goals, local context
Working through challenges together is easier when you are all aligned to one set of goals. The Triple Aim – improving health and wellbeing, improving the quality of services, and reducing the cost of care –provides that shared goal, an ICB’s North Star which should guide the what, how, who and when of their work. Systems have been given a fair amount of freedom in determining how they will deliver Triple Aim priorities, recognising that patient needs and NHS services vary from place to place. But there is a balance to strike between choice and complexity, and while there is an argument for more functions to be standardised to improve consistency, context is key.
All ICBs must balance quality, use of resources and access to services, but their population needs and wider health determinants may vary considerably. We need to draw on the benefits of blueprints, while building in the flexibility to adapt to local needs. This means aiming for a simple rather than a simplistic approach – one that can be adapted according to system context and be flexible enough to respond to unexpected or urgent pandemic-style demands. Population health data is key to this. It provides the necessary segmentation to enable each ICB to define the scope of work that is required to deliver the Triple Aim locally, through a series of priorities that are meaningful for their communities.
Shared goals should dictate the structures required to enable local priorities, albeit broadly aligned to the national framework. If your system is clear about its aims and priorities and can tie these back to both the Triple Aim requirements and your own population health data, you can determine what is needed to support that work. Teams, finances and performance measurement all need to be geared towards creating and driving behaviours which support your aims.
Measurement is often at the root of negative tensions between trust and ICB responsibilities which puts managers in a difficult place. Performance management has not developed at the same pace as collaborative working. It’s still often seen as a tool to berate providers with and drives transactional, short-term behaviours. ICBs need to invest in developing how they measure outputs, outcomes and benefits realisation in line with shared goals so that governance keeps pace with system-wide working.
Leadership and management skills
Strong leadership skills are needed throughout organisations to set and be accountable for future direction, particularly when implementing new ways of working. Investing in task-driven management skills is equally important. Managers need the skills to plan the resources, people, infrastructure and money to achieve tasks and take responsibility for their delivery.
Nurturing leadership and management skills often falls down the priority list as patient care rightly dominates. The trick is in finding a balance, recognising that without those skills you may never fully realise your patient care ambitions because you haven’t got consistent advocacy and focus throughout the system enabling effective pursuit of your goals, and accountable responses to both success and failure.
Ultimately, we need to recognise where we are. ICBs are still relatively embryonic and the enabling structures and operating processes required to encourage system-wide working are still being developed. We’re asking people to radically change how they do things, how they own decisions collectively and even to work in ways that may feel detrimental to their traditional ‘home team’. There’s no quick fix here – but establishing readiness for change, building trust, clarifying shared goals, and investing in the leadership and management skills to support these changes will accelerate the shift towards the opportunities of tension and away from duplication and inconsistency.
