PATIENT CARE
The Government recognises many of the issues and has taken steps through various initiatives to try and address some of them. For example, it has supplemented markets with network arrangements, trying to encourage networks of care. However, there has been a failure to align structural reform with pre-existing process and practice on the ground. If these networks are imposed in a way that ignores pre- existing collaboration across providers, which they often are, then they tend to fail. Children’s care networks, such as that around paediatric nephrology, are a good example of this.
Elsewhere you have initiatives, such as that in Greater Manchester, where health and social care budgets have been put together and devolved to the local level to allow decisions about integrating care across health and social domains to be made locally. An issue here, however, is the lack of additional money to help bring about the change. Merely combining and devolving budgets will not necessarily produce better integrated care because there are vested interests in the system.
Hospitals need to discharge people more effectively and safely if they want to solve their bed blocking problem. But, in reality, the hospital management may not easily be persuaded to hand over a proportion of its budget for social care.
Sustainability Transformation Plans
Sustainability Transformation Plans (STPs), take a system level approach to integrated care where providers and commissioners are brought together, including health, social care and other agencies, to devise an appropriate solution – it is ‘an accountable care system’. STPs are promising and gathering pace, but politics still gets in the way. The outcome from STP discussions may be that it makes sense to close, move, or concentrate certain services in a particular hospital. However, resistance from local communities, and negative reports in the media, often means that the backlash can prevent progress. Hospitals are keen to retain prime position in the system, which commonly acts against integration. What has been conspicuously lacking from the NHS reform initiatives is a focus on the processes that are needed in order to make any structural reforms a success. Structural reform on its own is not enough. We need to think about building capacity in the system to make integration work at a process level. This is where organisational management expertise becomes invaluable. There are four process issues, in
particular, that are worth highlighting where action is possible and would make a significant difference: knowledge mobilisation; distributed leadership and accountability; collaborative strategy; and workforce development - each of these areas has been the subject of in-depth research
within the Organising Healthcare Research Network.1, 2, 3
1 Mobilising knowledge
To begin with, the provision of first-class integrated care for long-term conditions is not possible without the mobilisation of knowledge across organisational and professional boundaries. Unfortunately, many people seem to equate the concept of knowledge mobilisation with the implementation of an IT system that facilitates data sharing. And that is part of the problem.
Knowledge is different from data. Knowledge is embedded in practice. This is about ensuring that the different professionals in organisations understand each other’s perspective and are able to broker knowledge to each other in real time, in ways that make sense to the other party.
2 Making distributed leadership and accountability work
Work needs to be done on aligning performance. Typically, under the existing performance management systems different parts of the organisation point in different directions with respect to the performance indicators that they need to meet. A classic example is targeted waiting times for A&E. If your job is likely to be at risk for not hitting a target you might, as a hospital manager, keep ambulances waiting outside A&E and not count them as coming into the hospital until you know that you can hit your target. However, somebody in the ambulance trust will have their job linked to time targets for the ambulance service that is being provided. If the ambulances are stuck waiting outside at the hospital then there will not be enough ambulances to respond to calls. Professionals will orientate towards their
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discrete professional indicators. A lack of performance indicators aligned to delivery of the overall service across domains, coupled with intense scrutiny and cost and quality pressures, creates incentives for organisations, or parts of an organisation, to act in dysfunctional ways that lead to inefficient and ineffective delivery of care. It encourages gaming and fragmentation of the system. Instead we need broader, more sophisticated performance indicators that relate to overall service provision over the long term, rather than just the narrow and very direct performance indicators, such as waiting times at A&E.
In turn this will create the conditions to allow leadership to be distributed across organisations and professions, rather than having hospital medical leadership as the dominant force, for example. At the same time this must be supported by collective responsibility.
At present there tends to be a patchwork of discrete accountabilities, with each individual in the care provision chain feeling that their duty to the patient is discharged after their personal interaction with the patient. Accountability is important, but we need to encourage a sense of collective responsibility for care of the patient over the longer term, focusing on long-term overall outcomes, particularly where care is discontinuous.
3 Collaborative strategies
In the current fragmented system individual service providers, whether in health, social care, education or another domain, develop their own strategies in isolation at an organisational level.
One reason that they do this, for example, is because marketisation and competition incentivises organisations to seek competitive advantage over other potential providers as
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