Creating the conditions for integration.

A conversation starter. Authors: Sam Keighley and Hayley Lever with learning from Greater Manchester and Yorkshire.

On 26 November, NHS England and NHS Improvement published Integrating care: next steps to building strong and effective integrated care systems across England. It builds on previous publications that set out proposals for legislative reform and is primarily focused on the operational direction of travel.

In the introduction to the paper online, it says

This builds on the route map set out in the NHS Long Term Plan, for health and care joined up locally around people’s needs. It signals a renewed ambition for how we can support greater collaboration between partners in health and care systems to help accelerate progress in meeting our most critical health and care challenges.

Over the last two years, ICS’s have been formed across England.  In an integrated care system, NHS organisations, in partnership with local councils and others, take collective responsibility for managing resources, delivering NHS care, and improving the health of the population they serve. Integrated care systems have allowed organisations to work together and coordinate services more closely, to make real, practical improvements to people’s lives. For staff, improved collaboration can help to make it easier to work with colleagues from other organisations. And systems can better understand data about local people’s health, allowing them to provide care that is tailored to individual needs.

By working alongside councils, and drawing on the expertise of others such as local charities and community groups, the NHS can help people to live healthier lives for longer, and to stay out of hospital when they do not need to be there”.

The introduction to the paper makes it clear that this is about learning from what is already strong.

We want every part of the country to build on the earliest ICSs’ experiences. It details how systems and their constituent organisations will accelerate collaborative ways of working in future, considering the key components of an effective ICS and reflecting what a range of local leaders have told us about their experiences during the past two years, including the immediate and long-term challenges presented by the COVID-19 pandemic”.

As we disussed the paper, with colleagues in health, physical activity and community organisations from Greater Manchester and West Yorkshire, we recognised that this was an opportunity to;

  • Notice and illuminate some examples of what is already going well in each place.
  • Share learning about the principles, ingredients or conditions for integration.
  • Consider how we build on what we’ve collectively learnt, to grow and spread integrated approaches.

We have captured some learning, examples and stories here, with the aim of those being a catalyst for a conversation with other colleagues in health, care, physical activity and beyond. The themes, principles and learning are widely transferable to any of us who are pursuing an ambition for health creation.

Around the same time as we started this conversation, a Warren Heppolette shared this brilliant article by Sue Goss.

Sue Goss provides an amazing metaphor for how we can think about this, what we need to do, and how we would be well served by shifting from machine thinking to garden thinking in our change methodology;

We won’t succeed using machine mind. If we want humans to thrive, if we want human connectedness, and want people to feel free to use their creative energies and be fully themselves, we won’t get there through policies that treat them like cogs in a machine

“If we stop to think about what gardeners do, they spend a lot of time observing and noticing. They take time to understand the seasons, the soil, the environmental conditions, the cycles that life moves in. They attract the wildlife that helps to maintain equilibrium. They encourage diversity. They begin by creating a rich soil, in which everything can thrive. Then they work with the plants, finding them the conditions they need and protecting them from harm. Sometimes, discovering happy accidents of extraordinary beauty, they simply look, and smile. But gardeners, as well as tending and nurturing, also move firmly to control the growth of rapacious weeds and to prevent the spread of suffocating monocultures.” (p8)

It speaks so clearly of the opportunity we have; to continue to learn, grow and spread what’s good, cut back the approaches that are suffocating integration, and create the conditions for a stunning garden.

And we know that thinking and working together is better than growing things alone, so we’re inviting you to join the conversation and contribute from where you are.

Integrated systems support and enable active lives and tackle inequalities

The outcome Sam and I are committed to and have been discussing is that of health creation through active lives. We are taking systems approaches to tackling inactivity and inequalities in Greater Manchester and West Yorkshire which are taking root, growing and spreading. It is vital that our approaches make the most of the opportunities that health and care integration bring.

Two things need to happen:

  1. Future integrated health and care ecosystems need to be part of the solution to addressing inactivity and inequalities in place.
  2. The physical activity ecosystem needs to adapt and evolve to be a better part of the solution to health, wellbeing and reduced inequalities.

To understand how to create the conditions for these to happen, we all need to explore some key questions:

Observing and Understanding Meaningful Integration

  • When meaningful integration is happening, what do we notice?
  • What do we see, feel and hear that tells us that meaningful integration is taking place?

Growing and Spreading what is Good

  • What makes it that way? What are the enablers of change?
  • How do we illuminate the good, and consider the art of the possible?
  • What are the challenges, blockages and barriers in the way of meaningful integration?
  • How do we work together to remove them?
  • What are the indicators of change that can be made visible and captured and used to create greater change?

What have we learnt in West Yorkshire and Greater Manchester so far?

We are still near the beginning of our journeys, and as we are collectively working out where next, we know that sharing as we go helps us all to learn together, and change can happen more quickly and deeply.

We recognise the degree to which the national changes in the paper above, seek to solidify the way our systems have been starting to work. It presents some real opportunities to grow, and we take great encouragement from that. We will now have a national context to work in, that will create better conditions for the fertile soil we are nurturing in our places, to support growth. The new Sport England strategy, Uniting the Movement, also creates a better set of conditions in the policy sphere for systems working in physical activity.

We know that real change happens in place.

We have reflected how throughout our careers in health creation, community development and physical activity, we have always worked with people, communities and place at the heart. Even when our roles have covered much larger spatial footprints, such as a city or region.

We hope that this blog might help to demystify ‘place based working’ as leaders across the country and across systems engage with a place based approach to health. In the Integrating Care paper, the NHS has acknowledged the importance of ‘place’ and is seeking t find ways to engage and integrate at place level. It recognises it’s importance, and we hope that those who have and will continue to contribute to this blog are providing evidence of why place is so important, and how to put people and communities at the centre of integration approaches.

Connection, integration and action is taking place in our neighbourhoods, localities, better enabled by the conditions we can create at sub regional  and at regional level.

In the examples and stories we share below, we have considered what makes integration meaningful at all of these spatial levels- and how past models that describe “horizontal and vertical” integration can evolve in our minds, into models that describe how everything from the sky to the soil are part of one ecosystem. 

It’s important to say that individual examples or stories are like different plants in a garden. The beauty of any garden is in it’s diversity and in the variety of plants that bloom because of the unique conditions and microclimate.

In telling some stories from our places, we are not suggesting that we should grow the same things across the whole country. Each place has it’s own conditions which enable things to flourish in their own ways…and each place has it’s own weeds to deal with (barriers and blockages to overcome).

Thankfully, we can all swap seeds, transplant seedlings and enable things to grow in their own beautiful ways. And there are some common weeds, which we can find ways of removing together. Which is why we want everyone to tell their stories.

Stories of integration, change and growth.

At a West Yorkshire layer, Yorkshire Sport Foundation has been having collaborative conversations with West Yorkshire and Harrogate Health and Care Partnership for around a year,  about how physical activity and sport can support a wide range of health and wellbeing objectives, including, but not exclusive to, the prevention agenda.  This initially led to aligning / integrating physical activity within the ICS’s maternity system review last year; using a public health approach and using evidence and insight gained from expert groups including women and families, a set of recommendations were produced that are now being implemented at place (unitary local authority) layer meaning that physical activity messaging and services will be part of all pre, during and post pregnancy conversations and services.

From late spring / early summer, Covid 19 and the first lockdown significantly accelerated opportunities to align and integrate physical activity within a  much wider health and wellbeing context.

  • Through whole system (including economy, health, academia, transport, sport and physical activity, local authority) Big Conversations convened by Yorkshire Sport Foundation (YSF),  the huge value of physical activity as protection against Covid 19 and other infections,, including reduced symptoms, and in improving mental wellbeing  became very clear. 
  •  A subsequent paper produced by YSF, which  set out changes that could be made across systems to make it more accessible and normal for people from all communities to be active as part of their everyday lives (YSF Recovery and Renewal Asks). This paper led to a conversation between YSF and West Yorkshire and Harrogate Care Partnership about how to consolidate the alignment and integration of shared objectives .  A paper was then taken to the System Leadership Executive Group in November which set out an ambition to integrate physical activity into all programmes and pathways across the Health and Wellbeing system in West Yorkshire.  This was received very positively  by leaders.

 The challenge is now on to make this happen. There are 3 key challenges (at least!) for us here:

  1. Connecting with our six places; this achieved with some parts of each local authority, including public health colleagues, but not wider local authority or wider system partners in every place. This is where partnership mapping will really help us.  
  2. Developing trust, understanding and collaboration,  hearts minds etc of players across the system to make physical activity part of every touch point. We are keen to explore creative ways of doing this, to grow what we have started.
  3. Making sure that if we can achieve the above, the conditions and support are there for people to be active; e.g. environment, VCSE sector, ‘leisure’ providers, transport, open and green space and other policies. Again, we are keen to explore our shared learning and thoughts around this.

What were the conditions which created these opportunities? 

There were a number of conditionsin place and/or developed that generated momentum for strategic buy in and energy to turn the dream into reality:

  • A new Population Health Programme was established, including a Prevention Network providing the environment to build discussions and enthusiasm across a wide range of stakeholders.
  • There were physical activity champions in several layers of the ICS system; Population Health Manager, several other Programme Leads, local authority Chief Executives, Clinical Commissioning Groups Accountable Officers and other leaders within this system. This meant that initial exploratory conversations easily identified shared space to collaborate towards shared ambitions, creating the shared energy for collaboration. 
  • Some of the ICS system leader champions were already involved in collaborative structures  around physical activity contributing to societal challenges in their own local authority areas. One of these is  the Calderdale Local Delivery Pilot which has done some successful work around integrating physical activity within the local  social care system, link to Calderdale Director of Adult Services;
  • Capacity within the ICS system. Collaboration in West Yorkshire is well developed over many years which means resources are available where it is most needed. This presents opportunities to explore, think and actively work  together.
  • As a result of capacity in the system, there is a growing history of the ICS working with place-based colleagues on wicked issues and learning. In effect physical activity has become a wicked issue.

As a result of capacity in the system, there is a growing history of the ICS working with place-based colleagues on wicked issues and learning. In effect physical activity has become a wicked issue. Over the last few years, Yorkshire Sport Foundation has also developed relationships with place base colleagues and supported the creation of structures and spaces which act as a platform  for colleagues across place layers to come together with shared commitment and to provide leadership around physical activity. Working collaboratively, we have realised that many of these place colleagues are the same and this has made for constructive conversations around  integrating physical activity across West Yorkshire health and wellbeing systems

In West Yorkshire then, the conditions presented good opportunities for collaboration, alignment and integration. What about if none or only some of these conditions are in place, making it more difficult.  As a first point, it becomes more important than ever to enter conversations in listening mode, to really understand your local health system, how it works, its priorities and the pressure it is facing. Really listen here, and spot any opportunities you can where physical activity and sport can help achieve those priorities and/or mitigate pressures.

And are there things that national partners can offer, that help create better conditions for local collaboration? Collating and sharing learning about where things are working well, what is the best of this work for example.  Sport England could play a really important role in this space. 

We also know that there has been tension in the health system for many years about the need to invest in prevention to save money upstream – and extend years of healthy life- without being able to release resource from upstream for this work because the demand is high in the present.  There is insufficient flexibility in local systems budgets to invest in test and learn prevention activity whilst maintaining the investment in clinical resources required until prevention activity reduces the demand for clinical interventions  (Marmot’s description of the health service as failed prevention).

So, could  national partners including Public Health England (or their successor body), Sport England or others, collaborate in ‘test and learn’ prevention programmes and, as part of that, contribute resource that to prevention activity to help provide evidence required to  enable local system leaders to agree to invest local system resources longer term in prevention  programmes.    And what are the challenges we’ve identified so far?

In the week we were writing this, Sheffield GP Ollie Hart did this brilliant podcast with The Compassionate Leadership Podcast series. Their introduction gives a great insight into his approach and way of working.

Ollie Hart is a GP at Sloan Medical Centre Sheffield, Director of Peak Health Coaching, Clinical Commissioning Lead, social media influencer, and innovation leader in healthcare and wellness.

His vision for the future of health and wellness in the UK involves inviting the individual and their community to take a more prominent role, as opposed to the healthcare system. All the research suggests that the impact of the system, based on a ‘medicalised model’ is far less than was imagined. The behaviour of the individual and the support provided to them by their community is the dominant factor in their health and wellbeing.

He believes the pandemic has demonstrated that alternative ways of doing things can be better: video appointments and the vaccine delivery model, involving collaboration between clinicians, volunteers and the community, are two examples.

Over time during his practice as a GP, Ollie discovered that the medical interventions he prescribed were often less effective than when he supported people in understanding their condition, and in adopting healthy behaviours. He learnt a lot of his health coaching skills in a pain clinic, where the drug treatment options were limited. He finds having good therapeutic relationships “recharging,” for him as well as his patients.”

Greater Manchester

At a Greater Manchester spatial layer, we have been working towards integration of the health, care and physical activity ‘systems’ since 2015, as the city region began its devolution, health and care integration and transformation journey in earnest and we wrote the first GM Moving Blueprint for Change.

Source: Greater Manchester Health and Social Care Partnership

GM Moving has been more and more integrated with the wider reform and transformation agenda since then, and our evaluation and evidence work has documented this journey and our learning so far. We are already better able to understand the enablers of change, the system, organizational and individual capabilities to make change happen. The most recent capture of this is shared here.

As we refresh GM Moving this year, we are drawing on the learning since 2015, and our growing understanding of what makes change happen. Creating the conditions for a movement to grow, and for meaningful transformation and integration to take place is as much about how we work, as it is about what we do.

At the Greater Manchester spatial level, strategic leadership across health and care, transport, public service reform, physical activity and VCSE sector form the GM Moving Executive Group. This group steers the work of the whole GM Moving Plan, enabling collective leadership across twelve priority areas, seeking to bring about culture change, system change and behaviour change together.

Enabling work on system leadership development, marketing, comms and campaigns, engagement and evaluation supports all of this work. A series of articles captures this journey, and the latest local pilot process evaluation can be found here.

In the ten localities and the neighbourhoods of Greater Manchester, the integration of health, care, physical activity for health creation starts to become more visible and tangible.

Our ten Local Care Organisations, the local VCSE infrastructure organisations, leisure trusts and other key parts of the system are working more closely together with people and communities at the heart. When this is working well, we see strategic leadership enabling collective and integrated leadership and decision making. We see governance and processes changing to better support person and community-centred approaches. We see local people involved and engaged, and effective work across the system.

All this has never been more evident than during the pandemic, in the way that neighbourhood hubs, mutual aid and vaccination efforts have worked, illuminating communities, public services, health and care systems playing to their strengths, and all playing their part in keeping GM Moving along the way.

When we started the Local Pilot with Sport England in 2018, the first thing we did was bring together people from across the system in each of the localities. The first ask was for each locality to bring a group of VCSE, public health, leisure trust/provider, commissioner and active travel leads together, to develop integrated approaches to work on all the influences of inactivity in a place. The pilot seeks to embed physical activity into the locally developed approaches to social prescribing, asset based community development and active travel. This story from Stockport shows how system integration is creating the conditions for change.

At neighbourhood level, the person and community centred approaches, asset based community development and system integration in Woodley provided the inspiration for the Local Pilot approach. It continues to grow in exactly the way that Sue Moss describes in Garden Mind, even down to the community allotment that opened last year.

There are a few films that bring all this to life. They show how people moving more and active lives are woven in to their approach, as they support and enable people to live better. The community connectors play a vital role in supporting strengths based conversations with local people, supporting their wellbeing in the widest sense. The opportunity that community connectors, link workers and other social prescribers offer across Greater Manchester and the whole country, is massive. There is much to learn from the Alvanley approach, and as is clear from the films. It’s all about the people, the approach, the values and principles that guide the work. And the passion, compassion and energy of people who care deeply about their place.

In Trafford, this story is a great example of how a text message from a GP can make all the difference in supporting and enabling people to get moving.

In Manchester, MCRActive have sought to build on local assets by partnering with Manchester City Football Club (MCFC), and a local family GP practice. This pilot aims to test whether the involvement of a professional football club alongside social prescription and activity tracking technology will help influence inactive residents of East Manchester to be active.

The partnership emerged out of conversations with the Chief Medical Officer of Manchester City, a GP at Five Oaks Surgery and staff from MCRactive. Their conversations were sparked by the population health challenge facing the region: “We were identified as recording the worst scores in every population health measure out of around 180 CCGs, with the inner-city proving the most unhealthy across the county. Activity levels were not good either.

This situation was particularly frustrating due to the huge investment in sporting infrastructure in the M11 area, with the world class facilities including the Etihad Stadium, the National Squash Centre and Velodrome being located in one of the highest areas of inactivity:

They are scared to get involved as thinking people would be clad in lycra. Despite the building being 50 yards away from their homes, they think it’s ‘not for us’”.[1]

The programme named MatchFit targets those aged 40+ who are at risk of non-communicable diseases and are insufficiently physically active in the M11 postcode area of Manchester who are also registered Manchester City supporters. Patients who fall into this category have been identified through varying channels including direct mail from MCFC, leaflet drops at popular community locations, including the chip shop and pubs and through grassroots social networks. Once identified, individuals are invited to attend an NHS Health check at the Five Oaks Family Practice. During this initial GP contact vital health statistics are collected[2] in order for the GP to run risk assessments. The mental health and wellbeing screening tool WENWBS, is also administered to the pilot participants.[3]

After screening, patients are invited to attend a GP 1-2-1 session at the prestigious Tunnel Club within the Etihad stadium. This meeting takes place in an area of the stadium normally reserved for players’ families and high ticket-paying corporate hospitality guests. This provides a sense of excitement due to the kudos and exclusivity of the offer.

What’s the transferable learning?

The stories we’ve shared above are just a few examples of what has been happening so far in our places. There are examples right across our regions, and across the country, and we want people to talk about them. We could write a book on this topic, and one day maybe we will. But in the meantime, we’ve captured some of the key enablers and barriers to integration as we see them. Again, it would be great to hear yours.

Enablers: Creating the conditions for growth and flourishing.

  • Finding out what matters to people, and how that aligns with what matters to you. Finding the sweet spot where there’s an opportunity to work together. And in working together with shared purpose, relationships grow. Trust builds and many flowers bloom.
  • Progress requires engagement, leadership and action in all layers of the system; regional, sub regional, local authority place, neighbourhood (PCN or other)  Place – regional, sub regional, neighbourhood levels.
  • Trust, collaboration, relationships are key. There are some key leadership approaches and behaviours that can enable change.
  • Honesty about the barriers and blockages, talking about them and working out how to shift them, is key. This can only be done once trust has grown.
  • People that approach complexity and conflict with curiosity, and who work together to find the blended approaches, rather than argue over binary views or choices. They look for the and, rather than the either/or. A conflict transformation approach is vital.
  • Place based investment approaches and principles of subsidiarity are important. We need to find ways of understanding what proportionate universalism looks like in practice and use it to guide our collective investment of time, capacity, resources and cash.

Blockages and Barriers: cutting back and controlling the weeds.

We all instinctively know, feel and experience what gets in the way of growth. We are getting better and talking about these things and opening up healthy conversations about what needs to change. These conversations can only take place where there is shared purpose and deep trust.

Otherwise, it’s an argument. It’s finger pointing. It’s them and us- whether that’s national to local or between those in the local ecosystem. We need to talk about the blockages and barriers, and work together to remove them, and create the best conditions for change.

  • Inflexible ways of working that can’t adapt or support integration.
  • Commissioner/provider split and commissioning approaches that aren’t aligned to shared purpose or outcomes.
  • Spaces and conversations where people are not able to participate as equals.
  • Old Power structures, dynamics and ways of working.
  • Measurement and targets that don’t measure what matters and drive unhelpful approaches and behaviours.
  • A national approach that sets out with the best intentions but doesn’t seek to truly understand people and place, or local assets, as leaders operationalise and implement the approach.

Indicators of Change?

At the beginning of this conversation, we explored the question of how the national changes could best create the conditions for change, and whether a set of national indicators would help. We need to think carefully through the consequences of the belief that we can mandate for change, control it or drive progress through top down measures and targets. This has failed us before and will fail us again.  Mandation doesn’t grow ownership. It has little energy or discretionary effort. It leads to compliance bodies and rules which are distant from the people doing the work and those they serve. Mandation can be a real cap on transformational change – people will feel obliged meet the target, and no more. At its worst, it creates the conditions for adherence to rules and gaming of the system to hit those targets. Prescription removes the need for leadership and stifles its growth.

A different way…

It has served us better in the past, and will as we go forward to develop shared purpose to unlock contributions. The energy in this is boundless, and a movement grows. So we need to create conditions; a set of principles and ways of working that give a framework in which people can work towards the shared purpose. This can be grow real ownership locally and support us to work alongside the communities we serve. Permissive frameworks from national or regional bodies which challenge us on outcomes can be more useful than targets or instructions.

Those doing the work can then be challenged on the outcome and the ‘so what’, and what have we learnt that can help us to grow? The greatest transformational change happens when we garden together through shared purpose, principles and approaches. The soil and the groundwater are equally important as the sun and the rain. Bottom up, top down and middle-out approaches are key.

Where next?

We want to gather more stories of meaningful integration and change. A bit like the open gardens each summer, where people look around, ask questions, learn together, enjoy the fruits of their labour, then return and plant things in new places, or try new things in their patch.

So please join in. You can share your stories in many different ways, and we’re not looking for show gardens. We’re looking for works in progress, with buds starting to open or areas of the garden that are blooming… even if other bits are still covered in weeds and need some attention. Certainly, our gardens are imperfect, but we have made a start in some areas, and they show great potential!

Comment below, tweet or share your stories online, or set up a zoom room and invite others to join a conversation. Meaningful integration of health and care offers us opportunities to better support more active, healthy, happy lives with our people and communities.

Let’s grow the movement together.

Appendix: Useful reading

https://www.kingsfund.org.uk/blog/2020/12/nhs-england-and-nhs-improvements-proposals-new-legislation

https://www.england.nhs.uk/integratedcare/case-studies/

https://www.kingsfund.org.uk/blog/2017/11/transforming-health-care-greater-manchester

[1] Interview with Manchester Local Care Organisations’ Chief Medical Officer, February 2020.

[2] Postcode; Age; Gender; Ethnicity; Height; Weight; Systolic blood pressure (mmHg); Cholesterol HDL & Total Cholesterol and HbA1c).

[3] https://warwick.ac.uk/fac/sci/med/research/platform/wemwbs/

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