Achieving integrated care

The LGA and the Social Care Institute for Excellence have joined up to produce an accessible and practice resource that supports local systems in fulfilling their ambition of integration.

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The 15 actions prioritised in this resource draw on evidence about what works from international research, emerging best practices and engagement with our own stakeholders and partners. The actions are deliberately aligned with national policy, legal frameworks and regulatory guidance, but most important, they allow for local variety in system design and service delivery to flourish.

We envisage a “whole system” approach in taking these actions forward, involving system leaders, health and social care commissioners and providers, front-line professionals, local communities and local people. By applying these actions, local partners will be able to focus on three key elements:

  • the delivery of person-centred coordinated care – i.e. the core objective of integrated care
  • the building of local “place-based” care and support systems
  • system leadership for integration.

For each action, the resource sets out the rationale, ‘How to’ tips, and signposts to the underpinning evidence and examples of good practice.

Foreword

We must “break down traditional barriers between care institutions, teams and funding streams so as to support the increasing number of people with long-term health conditions, rather than viewing each encounter with the health service as a single, unconnected ‘episode’ of care”.

That is the ambition set out in the NHS Long Term Plan.

But there are many hurdles to overcome if the ambition is to become reality: cash and workforce shortages; one free at the point of use, the other means-tested; different regulatory regimes; incompatible IT systems; differences in professional cultures and approach.  Taken together, this set of challenges has bedevilled policy makers for more than 30 years.

Nonetheless, progress has been made to bring services together and create more integrated person-centred care, albeit on small-scale and in pockets. It is not for want of knowing what works; if implemented properly, we know that a range of interventions can make a difference, such as personalised care plans, social prescribing or multi-disciplinary teams. 

We also know more about what system-wide conditions need to be in place for integrated care to flourish: effective systems leadership; coproduction and citizen involvement; joint commissioning and integrated workforce strategies.

However, knowing what works, and knowing how to implement it locally are very different things; often we may understand the research evidence, but struggle to translate it into meaningful actions on the ground.

That is why we have developed this new resource “Achieving Integrated Care: 15 best practice actions”.  The resource seeks to translate the best available evidence – as set out in Shifting the Centre of Gravity – into clear actions for local systems leaders, commissioners and practitioners.

The material proposes a range of actions, on topics as diverse as risk stratification, access to information, resource allocation and integrated commissioning. For each action we explain why it is important, how to achieve it and who needs to own it. It also provides links to the latest evidence, tools, resources. To demonstrate what is possible, case studies are provided as exemplars.

Delivering person-centred integrated care remains one of the greatest policy and implementation challenges facing health and social care; but it is a prize worth working for. We hope that this resource can contribute to making that task more achievable.  

Rt Hon Paul Burstow, Chair, SCIE

Sarah Pickup, Deputy Chief Executive, LGA

Introduction

The Local Government Association (LGA) and the Social Care Institute for Excellence (SCIE) have joined up to produce an accessible and practical resource that supports local systems in fulfilling their ambition of integration. From experience working with local systems, we know that the journey towards integrated care takes the commitment of time, energy and resources from all local partners. Change can be slow, with setbacks common, but there are a handful of actions local leaders can take to accelerate progress.

The principles underpinning the actions

A number of core principles underpin the fifteen actions. First, integration is not the end goal in and of itself. Instead, it is a means towards achieving the goal of better, joined up care. Integration creates the opportunities for transforming people’s experiences of care from disjointed to coordinated, reactive to proactive, and service-orientated to personalised. Effective integration should enable people to live healthy and independent lives, and care planning and coordination should build on an individual’s strengths and preferences. We have adopted some of the ‘I/We’ statements from Think Local Act Personal’s  ‘Making It Real’ framework to further highlight the way in which a particular action relates to the expected outcomes for both people who use (“I” statements) and people who provide (“we” statements) a service.

Integration should also support the building of community capacity for prevention, early intervention and “place-based” care and support. ‘Place’ is an integral aspect of the best practice actions, but we recognised that the concept of place will mean different things in different contexts. Therefore, we suggest “place” be defined by local partners and used flexibly to accommodate a range of geographic footprints and population sizes. For example, in some instances, place may mean as small as a neighbourhood; in others it will reflect the political boundaries of a local authority; and in some instances place will defined as regional. The principle for defining place should be one that optimises collaboration between local partners - and where there is a clear purpose for working and across organisational or institutional boundaries.

Finally, this tool is designed to support improvement and not performance management. Our consolidation of key sector research and best practice examples is intended to help local systems identify areas for improvement and introduce sound approaches for accelerating progress or tackling the barriers to better care. In particular, the resource draws on:

Realising person-centred coordinated care

Risk stratification

Identify the people in your area who are most likely to benefit from integrated care and proactive and preventative support

‘Making it Real’- I/We statement

“I can live the life I want and do the things that are important to me as independently as possible.”

“We work in partnership with others to make sure that all our services work seamlessly together from the perspective of the person accessing services information or advice if needed.”

Why take this action?

To increase the effectiveness and efficiency of integrated care and proactive support.

Who?

Integrated care leads, supported by public health and data analysts- (GPs, care coordinators, nursing and social care - to apply needs assessment criteria reliably)

How to achieve it

  • Use local population information from health and social care databases to identify cohorts of people “at risk” of dependency, often with multiple or complex long term conditions, and/or with high needs for care and support. Risk stratification and population management tools categorise people according to the severity of their needs.
  • Usually, these individuals will be known to multiple agencies, and can be identified through need assessments, such as for frailty, or because they frequent A+E, hospital discharge or other services. Consider offering training to ensure assessment criteria are applied reliably.
  • Informal information from voluntary services can also enhance local knowledge about people’s needs.
  • Analytics and modelling, using good quality data, also generate insights into demand or potential for early intervention services, from falls prevention to tackling social isolation.

Evidence and tools

Case studies

Access to information

Ensure individuals and their carers have easy and ready access to information about local services and community assets; and that they are supported to navigate these options and to make informed decision about their care

‘Making it Real’- I/We statement

“I can get information and advice that is accurate, up to date and provided in a way that I can understand.”

“We provide information to make sure people know how to navigate the local health, care and housing system, including how to get more information or advice if needed.”

Why take this action?

One of the challenges in any care system is to link people to the local services that matter most to them, especially in a complex system that can be difficult to navigate.

Providing good access to information, and navigation support, will facilitate people’s involvement in their own care planning, informed decision-making, prevention and social prescribing, and the personalisation of care.

Who?

Local commissioners should lead the development, working with a variety of local community partners.

How to achieve it

Good, accessible information systems should include:

  • a single database for the directory of local services
  • comprehensive listings of a variety of local services, from statutory to voluntary, and that offer care at home and in the community
  • an easily accessible “front door”, or single point of access, combining both telephone and online portals
  • resources for maintaining and updating the directory on a regular basis
  • “Navigators” or “community link workers” can offer support and guidance for those seeking services to help them to make an informed decision about their care
  • Creating the comprehensive directory requires a shared commitment across a local community with a broad range of partners. This includes commissioning its development and delivery, and the commissioning and training of care navigators.
  • It is critical to think beyond statutory services and to map the full range of local community assets, from housing support to prevention services offered by the voluntary and community sector. 

Evidence and tools

  • Social prescribing and community-based support (NHS England, 2019) – focuses on social prescribing, which enables all local agencies to refer people to a link workers, connecting people to community groups and agencies for practical and emotional support.
  • The Community Mapping Toolkit (Preston City Council) – helps community groups map assets in their local area and develop their own neighbourhood action plans.
  • Supporting integration through new roles and working across boundaries (King’s Fund, 2016) – suggests that new roles to support integrated care and better navigation through the system by working across organisational boundaries are only effective when they are part of a system-wide process of integration – valuing and reinforcing professional and organisational identities can help to develop trust and recognition, which can, in turn, facilitate closer team-working across organisational boundaries.

Case studies

  • Wigan community link worker service evaluation (Innovation Unit, 2016) – an evaluation of Wigan Community Link Worker Service, suggesting the service has made a difference in the lives of its clients and the difference – client stories suggest that CLWs help people ‘get back on track’, feel supported and become involved and able to contribute in their community.
Multidisciplinary team (MDT training(

Invest in the development and joint training of MDTs to transform their skills, cultures and ways of working

Multidisciplinary Teams (MDTs)- MDTs are the health and social care professionals who are jointly responsibly for assessing, planning, managing and coordinating the care and support that best meets the needs of individuals. These teams tend to include a local social worker, nurse, doctor/GP, and therapists – and possibly others like care navigators or link workers.

‘Making it Real’- I/We statement

“I can get information and advice that is accurate, up to date and provided in a way that I can understand.”

“We provide information to make sure people know how to navigate the local health, care and housing system, including how to get more information or advice if needed.”

Why take this action?

Team members work across organisational and professional boundaries, so they need to acquire new skills, adapt their ways of working and facilitate communication. Joint training facilitates a shared culture and practice.

Effective MDTs develop over time and with experience. Collaborative cultures, trusting relationships and reflective team learning are at the heart of team working.

Who?

Local commissioners to arrange the training; MDTs to participate

How to achieve it

A sustained investment in team development and joint training is essential, as it helps foster and secure the practices and protocols that underpin delivery of integrated care and better care outcomes. Topics for joint training include:

  • standardised approaches for joint assessment, care planning, care coordination, care management, and crisis response
  • making the shift from reactive to proactive and preventive care
  • working with shared care records, and information sharing
  • understanding and accessing the resources available for personal care plans, including personal budgets
  • personalisation and co-production methods, including shared decision-making
  • team development to improve working relationships and behaviours, joint problem-solving, shared accountability
  • involvement of link workers (care navigators) to support self-care and social prescribing
  • co-location of team members has been shown to enhance the ability of teams to communicate and collaborate.

Evidence and tools

Case studies

  • Delivering integrated care: MDTs case studies (SCIE, 2018) – shows that there are different ways to support groups of professionals and practitioners to collaborate successfully. Lincolnshire and Manchester have brought together those working within an identified locality into an MDT. Stockport has instead maintained single-discipline teams but enabled collaboration through shared principles, joint training and an emphasis on innovation and improvement
  • Integrating Better - 10. Case studies. Leeds: Multidisciplinary community approach (NHS England, 2019) – explores how Leeds has developed multidisciplinary community teams and how they located them into local communities to achieve better experience for people who use services, their families and their carers.
Personalised care plans

Develop personalised care plans together with the people using services, their family and carers

Making it Real- I/We statement

“I have a co-produced personal plan that sets out how I can be as active and involved in my community as possible.”

“We talk with people to find out what matters most to them, their strengths and what they want to achieve and build these into their personalised care and support plans.”

Why take this action?

Care planning that directly involves individuals and those who care for them is more likely to produce plans that build on the person’s own strengths and assets, support shared decision-making, and meet the person’s care goals.

Who?

Integrated care leads, clinical leaders and “users by experience” (to co-develop standards and practices)

  • Commissioners to facilitate learning programmes for MDTs and other assessors
  • Local system leaders to tackle barriers

How to achieve it

When care is personal, the focus is placed on the individual at the centre of their care – the whole person – and understanding that they know best what their needs are and how to meet them.

The starting point is the person’s own strengths and goals, with care planning directly involving the person in the process. Whoever is assessing needs and developing plans must adopt this guiding principle.

Realising the ambition of personalised care requires a cultural shift. As covered in action 3, training of multi-disciplinary teams and other assessors is needed to ensure that the expected standards and practices become adopted and second nature. Learning programmes should cover:

  • best practices for involving people in care planning and setting care goals
  • how to plan for prevention and self-care along with traditional services
  • supporting shared decision-making, patient activation, motivational interviewing, and other techniques
  • how to involve people’s families and caregivers in the planning process.
  • Personalised care planning is best facilitated by an effective and accessible system of shared care records, one that incorporates standardised documentation practices.

A personalised care plan is more than just the technical output of an assessment – it should encompass the quality of these plans from the perspective of the person. Finding ways for practitioners to receive feedback will support better care and improvements in future planning.

Plans must be reviewed on a regular basis, since people’s needs and goals will change over time as their underlying conditions and personal circumstances change.

Evidence and tools

  • Personalised care & support planning (TLAP) – through a series of case study scenarios, the tool shows what different journeys through personalised care and support planning could look like when delivered through integrated and person-centred arrangements.
  • Personalised care and support planning (LGA & NHS England, 2017) – sets out practical guidance on how to develop and implement a single personalised care and support plan, develop multidisciplinary approaches and put in place a single, named coordinator.
  • What to expect during assessment and care planning (SCIE & NICE, 2018) – describes what people should expect from social care staff during assessment and care planning, covering making decisions; support from an advocate; needs assessment; and care planning.
  • Using conversations to assess and plan people's care and support (Skills for Care, 2018) – outlines the key principles of conversational assessment, which are aligned with the principles and values of Think Local Act Personal, and support the Making it Real framework.

Case studies

  • Assessment and care planning: three conversations (SCIE, 2017) – describes the three conversations model, an innovative approach to needs assessment and care planning which focuses primarily on people’s strengths and community assets.
  • Digital care and support plan standard: case studies (PRSB, 2018) – examples of implementation of a standard for digital care and support plan, so that care plans can be effectively shared between patients, carers and all the health and care professionals involved.
Rapid response

Through a single-point of access, provide access to integrated rapid response services for urgent health and social care needs

Making it Real- I/We statement

“I know what to do and who I can contact when I realise that things might be at risk of going wrong or my health condition may be worsening.”

“We work with people to write a plan for emergencies and make sure that everyone involved in supporting the person knows what to do and who to contact in a health or social care emergency. We make sure that any people or animals that depend on the person are looked after and supported properly.”

Why take this action?

Having an effective crisis response in the community helps to stabilise changing conditions, keep people at home and avoid unnecessary emergency hospital attendances and admissions.

Who?

Commissioners, working with local partners

  • (As described in the NHS Long Term Plan, all CCGs within an Integrated Care System should be aiming for a single approach to urgent community care.)

How to achieve it

Commissioning an effective single point of access with 24/7 hour coverage enables an effective rapid response system to be deployed for people whose care needs require urgent attention:

  • a clear model of care and agreed protocols, including referral and escalation pathways, for handling urgent and emergency care needs that arise from the targeted population, whether they are people living at home, in care homes or elsewhere in the community
  • a fully integrated rapid response team, ideally available 24/7, delivered by a range of health and social care professionals with access to specialist medical expertise, as needed, who can triage and attend to the individual’s urgent needs
  • a single point of access – usually telephone triage in a physical hub – from which to coordinate the rapid response, and which is linked to a shared care record system.
  • The community-based urgent care system is suitable for any person at high risk of entering a crisis. This includes anyone receiving integrated care at home or in the community, care home residents, those who frequently attend hospital emergency care, or people recently discharged from hospital.

Evidence and tools

Case studies

Building place-based care and support systems

Operational framework

Create an integrated care operational framework that is right for the local area, and which aligns service delivery and service changes to a clear set of benefits for local people

‘Making it Real- I/We statement

“I have care and support that is coordinated and everyone works well together and with me.”

“We work in partnership with others to make our local area welcoming, supportive and inclusive for everyone.”

Why take this action?

Moving from a shared vision for the new local system to real change requires collaborating with providers to have a shared operational framework and performance goals.

Who?

Joint commissioners and integrated care leads, working with local providers

How to achieve it

  • Operational frameworks translate system leaders’ vision and strategy for integrated care to local place-based care and support systems. An operational framework will be unique to each local area; it is not a “one size fits all” approach.
  • Aiming to meet the needs of local people, and staying people-centred in focus, the framework should describe: how care will be organised and provided; how outcomes will be achieved, such as through local care networks and care pathways; the range of services available; and how prevention and early intervention are incorporated into the offer.

It should be co-produced by local providers, frontline staff and local people, so as to ensure:

  • the framework maximises the potential and capacity of local assets and resources, including the voluntary and community sector
  • prevention and early intervention services are incorporated into the plan 
  • engagement with frontline staff and local people maintains a focus on the development and innovation of local services
  • there is support for new ways of working, and that any structural or behavioural changes are understood
  • frontline staff will have the autonomy and freedom to work together.

Evidence and tools

Case studies

Integrated commissioning

Use integrated commissioning to enable ready access to joined-up health and social care resources and transform care

‘Making it Real- I/We statement

“I can live the life I want and do the things that are important to me as independently as possible.”

“We work in partnership with others to make our local area welcoming, supportive and inclusive for everyone.”

Why take this action?

The experience of care is more likely to be seamless where local providers and practitioners share accountability for care outcomes, the best use of joint resources and the management of risks.

  • Integrated or joint commissioning enables shared accountabilities and practices to work effectively.

Who?

Commissioners

How to achieve it

A single team of joint commissioners, ideally co-located, can better leverage the  co-ordination, pooling or alignment of local resources to create improved outcomes and experiences from integrated health and social care. (See also action 11 and  action 13.). Their work is underpinned by the local integrated care vision.

The options for integrated commissioning are:

  • section 75 agreements between CCGs and councils that create permission to pool or align NHS and social care funds
  • contracts with providers, including lead providers, which include risk-reward incentives and clear outcomes and performance metrics.
  • Commissioners cannot work solely in a transactional way. Instead, dialogue with local providers, clinical professionals and service users should be used to shape the delivery of the service model and full range of integrated care services, from prevention to urgent care in the community.
  • commissioners may need support to develop their negotiation, influence and engagement skills.

Evidence and tools

Case studies

Shared records

Identify and tackle barriers to sharing digital care records to ensure providers and practitioners have ready access to the information they need

Making it Real- I/We statement

“I know how to access my health and care records and decide which personal information can be shared with other people, including my family, care staff, school or college.”

“We get permission before sharing personal information.”

Why take this action?

Information sharing supports care planning, care coordination, proactive and urgent care management, as well as the personalisation of care, and workforce and service planning. What gets in the way are behaviours and assumptions about how to share data legally and functionally.

Who?

System leaders

How to achieve it

Access to shared care records is an important enabler of integrated care. A relentless focus on eliminating the barriers to data access and data sharing will accelerate local progress. To do this well, requires:

  • committed leadership, supporting culture change, openness and collaboration – beyond just introducing new technology – to reimagine work processes, professional interactions and the engagement of service users
  • strong information governance, including through formal information-sharing agreements and partnerships – acknowledging that users of services generally assume information is already shared
  • interoperability and standardisation, ensuring IT systems are able to communicate across settings and organisations
  • a focus on the relevance and quality of data
  • staff skills development and clear guidance to ensure consistent compliance with data protection laws and the wider regulatory framework   
  • processes in place to ensure customisable sharing, tailored to the person’s consent and service needs
  • user-centred design, developing the facility for people to have access to their own records
  • analytic capacity and capability to extract insights and monitor outcomes.

Evidence and tools

Case studies

Community capacity

Build capacity for integrated community-based health, social care and mental health services, focusing on care closer to home

Making it Real- I/We statement

“I can live the life I want and do the things that are important to me as independently as possible.”

“We have a clear picture of all the community groups and resources in our area and use this when supporting people and planning services.”

Why take this action?

To support people to maintain their independence and prevent unnecessary hospital or institutional care, it is important that there is capacity within community-based services to support prevention, early intervention, rehabilitation and reablement.

Who?

Commissioners, leaders from local statutory providers, including clinical leaders, and local people

  • (As described in the NHS Long Term Plan, the evolution of Primary Care Networks (PCNs) should align with these principles)

How to achieve it

  • An objective of integrated care is to provide services to people closer to home – or at home. This means developing a greater array of preventive, therapeutic and rehabilitative services in the community.
  • This requires the redesign of care pathways and the creation of new or expanded community-based services. Some services could be designed for delivery at home, and others might be accessed at a neighbourhood “hub”, which could provide primary care, community health, mental health, social care and voluntary sector services all in one place. Access to specialist care would support the management of long term conditions and urgent care, while an expanded offer of reablement would help people prevent unnecessary admission to hospital or care settings.
  • Commissioners should involve local people, their families and carers, as well as health and social care providers, in their planning efforts, so that the resulting services are better tailored to local context and priorities.

Evidence and tools

    • Reimagining community services: Making the most of our assets (King’s Fund, 2018) – focuses on services in the community, comprising both services commissioned by the NHS and local authorities as well as related services delivered by the third sector, the private sector, carers and families. The report proposes ten design principles that should inform the future planning and provision of community-based care.
  • Primary care home and social care: working together (NAPC & ADASS, 2018) – describes the importance of closer integration of social care with primary care to achieve better outcomes for users of services and local populations and highlights the value of the primary care home model as a framework for making this happen at scale and consistently throughout the country. Includes case studies.

Case studies

Partnership with voluntary, community and social enterprise sector

Foster partnerships to develop community assets that offer a wider range of services and support

Making it Real- I/We statement

“I feel welcome and safe in my local community and can join in community life and activities that are important to me.”

“We invest in community groups, supporting them with resources – not necessarily through funding – but with things like a place to meet or by sharing learning, knowledge or skills.”

Why take this action?

Actively cultivating partnerships with local voluntary services, housing associations and other community organisations will broaden the range of services people are able to access to keep them independent and well, such as services that support prevention, self-care and social prescribing.

strong>Who?

Commissioners working with the VCSE sector and local people.

How to achieve it

  • An objective of integrated care is to provide services to people closer to home – or at home. Limiting these services to statutory health and care ignores the often rich “assets” of the local VCSE providers, often already serving local people.
  • Think broadly about how to partner with the VCSE sector to develop community-based services, support and interventions that focus on prevention, self-care, independence and wellbeing.
  • Commissioners, working in partnerships, can:
  • reframe the narrative about people and communities – shifting the emphasis from deficits and needs, to strengths and assets, creating the right environment for community engagement
  • reinforce an ethos of co-production, taking a co-design approach to develop the services people want, and focusing on wellbeing, prevention and self-care
  • include voluntary-led services in local service directories to support personalised care planning
  • connect people to the wealth of local community resources and initiatives through a clear and intuitive signposting, social prescribing, peer mentors, link workers and care navigators
  • support and encourage the full offer of schemes and programmes run by the voluntary sector, including Shared Lives, community circles, time banks, etc.

Evidence and tools

Case studies

  • Integrating Better - 10. Case studies. Bracknell Forest: Changing care (NHS England, 2019) – This case study looks at what has made system change successful, particularly: the ‘Help Yourself’ portal; changes to the social care market; and the ‘Community Connector’ role.
  • Integrating health and social care: Croydon case study (LGA, 2018) - describes Croydon’s progress developing integrated care arrangements, including through the creation of Local Voluntary Partnerships which will be vital in organising and supporting the voluntary and community sector offer, so that initiatives such as social prescribing and the Integrated Community Networks know who they can signpost and refer people to for help in their communities.
  • ConnectWELL (SCIE Prevention Research and Practice) – describes a social prescribing service in Rugby, which provides health professionals with just one, straightforward referral route to the many Voluntary and Community Sector organisations, groups and activities that can help manage or prevent compounding factors of ill-health.

Leading for integration

Common purpose

Agree a common purpose and a shared vision for integration, including setting clear goals and outcomes

Making it Real- I/We statement

“I have care and support that enables me to live as I want to, seeing me as a unique person with skills, strengths and personal goals.”

“We work in partnership with others to make sure that all our services work seamlessly together from the perspective of the person accessing services.”

Why take this action?

A clear shared vision and common goals help develop integration and support the necessary behavioural changes for achieving better health and wellbeing outcomes.

Who?

System leaders, building on current local arrangements

How to achieve it

Without a common purpose and shared vision, integrated care will fall at the first hurdle, with commissioners and providers not working collaboratively towards the same goals.

It is vital for local system leaders to re-affirm their local vision for integrated care and the goals and outcomes expected for their local systems. This involves:

  • working together to align priorities and responsibilities, including overcoming cultural and performance challenges to establish a common language and set of objectives
  • co-designing and co-producing goals and solutions with those who receive health, care and support
  • building commitment, ensuring leadership is shared and rooted deeper within organisations, engaging middle managers, multidisciplinary team leads and frontline staff in their thinking
  • setting medium and long-term milestones, ensuring vision and goals are tangible, well-defined and measurable.

Evidence and tools

  • Stepping up to the place: integration self-assessment tool (LGA, NHS Confed, ADASS, NHSCC, 2016) – this self-assessment tool is designed to support local health and care leaders to critically assess their ambitions, capabilities and capacities to integrate services to improve the health and wellbeing of local citizens and communities.
  • The King's Fund: Population health systems: Going beyond integration care (King’s Fund, 2015) – aims to challenge those involved in integrated care and public health to ‘join up the dots', seeing integrated care as part of a broader shift away from fragmentation towards an approach focused on improving population health.
  • The King's Fund: Place-based systems of care (King’s Fund, 2015) – proposes that organisations need to establish place-based ‘systems of care' in which they collaborate with others to address the challenges and improve the health of the populations they serve.
  • The journey to integration: Learning from seven leading localities - leadership section, p51 -54 (LGA, 2016) – shows that development and ownership of a vision is critical across the area, and strong leadership across the area's organisations is essential to maintain focus and mitigate against the risk of change in leadership and loss of momentum.

Case studies

Collaborative culture

Foster a collaborative culture across health, care and wider partners

Making it Real- I/We statement

“I have care and support that is coordinated and everyone works well together and with me.”

“We have a ‘can do’ approach which focuses on what matters to people and we think and act creatively to make things happen for them.”

Why take this action?

Integrated care systems require people to work across organisational and professional boundaries to achieve success. This requires significant culture change.

  • A system-wide organisational development strategy that fosters collaboration at all levels is suggested.

Who?

System leaders

How to achieve it

Without a common purpose and shared vision, for system leaders, creating a joint strategy for organisational development will set the parameters for the culture changes expected at all levels of the system. How system leaders act and behave will demonstrate these expectations in practice.

The focus should be to develop mutual understanding and collaborative ways of working, including building capacity for tackling the “stickiest”, most intractable challenges that arise when different organisations or groups of people work together.

System leaders have the power to address:

  • accountability for decision-making at the most appropriate level – system, place, neighbourhood or individual
  • sharing accountability for the use of joint resources
  • facilitating opportunities for staff from different disciplines to understand each other’s roles and professional identities, building trust, relationships and joint ways of working – including through co-location where appropriate
  • creating opportunities for professionals from multiple settings and agencies to learn from each other and plan solutions and interventions together
  • developing integrated training opportunities, including offering rotational placements in different sectors
  • facilitating information sharing, including shared access to care records.

Evidence and tools

Case studies

Resource allocation

Maintain a cross-sector agreement about the resources available for delivering the model of care, including community assets

Making it Real- I/We statement

“I have care and support that is coordinated and everyone works well together and with me.”

“We work in partnership with others to make sure that all our services work seamlessly together from the perspective of the person accessing services.”

Why take this action?

Commissioning should be underpinned by firm shared agreements for how resources will be allocated in relation to outcomes, and how outcomes will be monitored. This should help to reduce or resolve competing financial incentives within the current system.

Who?

Systems leaders and commissioners of health and social care

How to achieve it

Some of the barriers to integrated care are financial, namely how resources align with the expected model of care; how they are made available to local providers through contracts; how joined up they are in terms of outcomes and contractual incentives; and whether the lines of accountability for delivery of value and outcomes are clear.

System leaders that actively address resource challenges and maintain cross-sector agreements will create greater scope for success. They need to:

  • define the shared budget available for the population groups targeted in each local place and in line with the model of care
  • agree how resources will be aligned or pooled, along with the legal and governance arrangements, including cross-sector agreements
  • identify the types of contractual models and financial incentives that will be used for managing provider contracts
  • ensure the incentives within the contracts correspond with the outcomes and service changes expected.

Evidence and tools

Case studies

  • Integrating health and social care: Dorset case study (LGA, 2018) – describes Dorset’s joined-up CCG and County Council approach to proactive care market management, integrated commissioning, brokerage and a contract framework – the ‘Dorset Care’ – initially focusing on home and community services for older people and is now extending into learning disability and mental health services.
  • Integrating health and social care: North East Lincolnshire case study (LGA, 2018) –  offers an example of an advanced whole system approach, underpinned by a shared vision for the ‘place’ and led by the ‘Union’ of the Council and CCG, which drives a joint approach to commissioning, service delivery and financing to the point that integrated working is seen as business as usual.
Accountability

Provide system governance and assure system accountability

Making it Real- I/We statement

“I am treated with respect and dignity.”

“We make sure that our organisational policies and procedures reflect the duties and spirit of the law and do not inadvertently restrict people’s choice and control.”

Why take this action?

As part of their public governance role, system leaders should regularly be monitoring progress and evaluating the outcomes and benefits of integrated care.

Key is demonstrating that integrated care is making a difference to local people and that resources are being used appropriately.

Who?

Local system leaders

How to achieve it

Most local systems have good foundations for assuring system accountability, but the continued evolution of integrated care systems will challenge these foundations and require strengthening – for example working over geographies larger than those for local political accountability for social care. Forging productive, trusting working relationships, building on existing arrangements, will continue to be an important activity for local system leaders.

Effective governance structures and processes will need to enable local priorities to be met by high-quality services and adequate resources; that decision-making is transparent and publicly accountable; that local populations have equitable access to care and support; and that the cultural changes associated with integrated care are fully realised.

Local systems may need to stress test their current governance arrangements and introduce important changes, reviewing the following important factors:

  • governance arrangements that are lean, transparent and not overly burdensome or bureaucratic
  • clarity about where decision-making and resource allocation powers lie within the system, and how different decision-makers will be held accountable – and to whom
  • an accountability framework that focuses on monitoring progress, assuring quality and delivering better outcomes and value for money for local people
  • agreed ways of working for tackling barriers to integration, solving joint problems such as workforce planning, and sharing resources; any new ways of working should build on existing legal agreements and other formal arrangements (eg data sharing)
  • clarity about local people’s influence and involvement in governance and decision-making.

Evidence and tools

Case studies

Workplace planning

Lead system-wide workforce planning to support delivery of integrated care

Making it Real- I/We statement

“I have considerate support delivered by competent people.”

“We work in partnership with others to make sure that all our services work seamlessly together from the perspective of the person accessing services.”

Why take this action?

A system-wide workforce strategy will ensure there is appropriate capacity and capability across all local settings to meet the ambition and goals of the local integrated care system.

Who?

System leaders, local providers from the public, independent and voluntary sectors

How to achieve it

System leaders should undertake workforce planning in partnership, and not in isolation, working with local provider organisations across health and care.

Local workforce strategies should be cross-sectoral in nature, covering the public, independent and voluntary sectors. They should address:

  • existing and future recruitment needs and retention challenges
  • the state of the local labour market
  • the skills and training required to work in new settings and in new ways
  • the advent and roll-out of new roles, such as link workers or care navigators
  • the availability of local resources for workforce development and training.

Using a whole-system approach to workforce planning will ensure local providers and commissioners are working in partnership to address workforce shortages, such as developing innovative and shared opportunities for recruitment and retention – and avoiding competition for staff. Including the independent sector in social care is of particular importance to the growth of home-based and community care and reablement.

The strategy should reflect the need to develop an integrated workforce by creating opportunities for professionals from multiple settings and agencies to learn from each other and plan solutions and interventions together. This is likely to produce integrated training programmes and rotational placements in different sectors.

Involvement of local education providers in the development of the workforce strategy recognises that they too play an important part in the building of local workforce capacity and capability.

Evidence and tools

Case studies

Risk stratification

Identify the people in your area who are most likely to benefit from integrated care and proactive and preventative support

‘Making it Real’- I/We statement

“I can live the life I want and do the things that are important to me as independently as possible.”

“We work in partnership with others to make sure that all our services work seamlessly together from the perspective of the person accessing services information or advice if needed.”

Why take this action?

To increase the effectiveness and efficiency of integrated care and proactive support.

Who?

Integrated care leads, supported by public health and data analysts

  • GPs, care coordinators, nursing and social care - to apply needs assessment criteria reliably

How to achieve it

  • Use local population information from health and social care databases to identify cohorts of people “at risk” of dependency, often with multiple or complex long term conditions, and/or with high needs for care and support. Risk stratification and population management tools categorise people according to the severity of their needs.
  • Usually, these individuals will be known to multiple agencies, and can be identified through need assessments, such as for frailty, or because they frequent A+E, hospital discharge or other services. Consider offering training to ensure assessment criteria are applied reliably.
  • Informal information from voluntary services can also enhance local knowledge about people’s needs.
  • Analytics and modelling, using good quality data, also generate insights into demand or potential for early intervention services, from falls prevention to tackling social isolation.

Evidence and tools

Case studies

Hospital discharge

Achieving integrated care: 15 best practice actions

Logic model for integrated care

Better Care support offer

Managing transfers of care – A High Impact Change Model

This model has now been updated in July 2020 to integrate emerging learning from responding to the COVID-19 pandemic.

For further information or to discuss what offer might be right for your system, please contact your Care and Health Improvement Adviser or email pch@local.gov.uk