The creation of Integrated Care Boards (ICBs) is designed to deliver collaborative healthcare services driven by population needs and patient outcomes – a much more formal approach to partnership working underpinned by statutory responsibilities and funding. In practice, however, the success of this new structure depends on a significant shift in the culture of how NHS and social care organisations operate. It requires unlearning deep-rooted ways of working and being prepared to pause, reflect and realign before moving forward. This is no easy task, particularly against a backdrop of treatment backlogs, lack of resources and an ongoing pandemic. Facing these realities, how can ICB leaders find the space, support and skills needed to drive what could be a transformative agenda for the NHS?
Care, not commissioning
The clue to the ICB challenge is in the title. They are integrated care boards not integrated commissioning boards. And this is what lies at the heart of the leadership challenge for those with a seat at the decision-making table. In most cases, those involved in the ICBs were commissioners prior to 1 July 2022. While the commissioning responsibility remains, how it is delivered has changed. We are moving away from services managed through contracts and service level agreements with output-focused key performance indicators. The new direction is towards outcomes-based services to deliver the Triple Aim of improving quality, increasing health and wellbeing and using resources sustainably.
This is a significant change and one for which there is no model. It requires experienced and successful individuals to completely rethink how they work. In many cases, people’s identities and job titles have been linked to responsibilities that are about holding people to account. Now their success will be judged on how well they collaborate with system partners to achieve consensus. How they can enable service delivery that is patient outcome led, even if it may mean their own organisation losing out on resources or funding. The required shift from competition to collaboration is substantial and won’t just happen. Those involved need the support to change gear, not only in delivering their new ICB responsibilities, but in setting an example that will filter across their organisations.
Creating space for change
One of the barriers that ICBs need to address is the endemic cultural and professional views that exist about different specialists and different parts of the healthcare system. This kind of historical baggage needs to be let go of purposefully and effectively, to enable collaborative working. ICBs are the ideal hub to drive and encourage this shift, by investing in new skills and allowing the time and space to adopt them.
With so many external challenges, there is a sense that change must be delivered at speed – that we must work more efficiently to tackle the demands of today while planning for the challenges of tomorrow. But significant value can be gained in slowing down to speed up. When you look at athletes, for example, their rest days are just as crucial to their performance as their training. The same principal needs to apply here. We need to create safe spaces for people to have collaborative discussions that move us forward.
ICBs also need to create the capacity to enable new ways of working by letting go of initiatives in their areas that don’t deliver the best value outcomes for patients. That includes being prepared to effectively vote against your own organisation, despite the pull from your own board, and work collaboratively with your ICB partners to achieve more. Achieving this is complex and is core to the leadership development work Arden & GEM is doing with ICB leadership teams. While we all have embedded cultural ways of doing and seeing things, there isn’t a one size fits all approach to enabling effective system working. To reinvent how we deliver care, we first need to be prepared to lose some of the practices or activities we hold dear, which will vary from organisation to organisation.
The ‘North Star’
In the absence of a ‘blueprint’ and recognising the conflicting demands of those working in both system and organisational roles, it would be easy to become rudderless and fall back into old, familiar ways of working. This is where the Triple Aim is so crucial. It provides both clarity of direction and legal impetus. Much like the rowing team whose every move was determined by whether it would make the boat go faster, ICBs must assess each move they make – will it improve access, will it improve use of resources, will it deliver better patient outcomes? And they must do so continuously. COVID has taught us that things can change rapidly and we should be regularly reassessing assumptions to keep activity on track.
There is nothing new about structural change in the NHS and partnership working in healthcare has been around for years. But there is a difference between partnership working as an add on, and fully integrated, statutory partnership working. By giving ICB leaders the support, space and confidence to pause and reset old assumptions, ICBs may well lead the way in enabling earlier intervention and preventative care to deliver better patient outcomes, improve overall health and wellbeing and make the NHS more sustainable in the longer term.
By Davo Ruthven-Stuart, Head of Organisational Development Consultancy, NHS Arden & GEM CSU
