Ruth Abrams is an organisational psychologist whose research focuses on the qualitative, workforce experiences of organisation, workflow, and service delivery within the healthcare sector. Her work includes research on role boundaries among homecare workers, work delegation within primary care, and multidisciplinary teamwork in healthcare settings.

Geoff Wong is a clinical research fellow whose research centres on making sense of complex health and social interventions in which context and human agency are key. His work focuses on applying a realist logic of analysis in evidence syntheses or evaluations to explain and understand these types of interventions.

The release of the NHS Long Term Plan last year has set many transformational processes in motion for community care. Of significance has been the transition of sustainability and transformation partnerships (STPs) into integrated care systems (ICSs). Designed to respond to local needs, ICSs are an alliance between the NHS, local authorities, and third sector organisations. To date, at least 14 ICSs have already been established across the country.1

Before COVID-19, the intention was to establish national coverage of ICSs by April 2021 … the NHS Confederation suggests that this deadline should still be upheld.

ICSs are intended to offer localised models of care and expand the community care workforce. For ICSs to successfully do so, they need to address the explicit challenges of: (1) encouraging ways of working that facilitate a move from a competitive model of care delivery to one of collaboration;2 and (2) expanding and extending the NHS workforce in the community. The latter sees the introduction of new roles (for example, pharmacists) and the reinvention of current roles, such as district nurses into, for example, care coordinators.3

At a local level, ICSs rely heavily on the capability of the NHS workforce to work across sites and practices collaboratively and in ways that maximise multidisciplinary teamwork. The sharing and delegation of work in this respect requires mutual respect, trust, as well as clarity, receptivity, and tolerance.4 Thus for ICSs to flourish, effective structural and organisational changes are needed.

Before COVID-19, the intention was to establish national coverage of ICSs by April 2021. Even in the midst of the COVID-19 pandemic, the NHS Confederation suggests that this deadline should still be upheld in order to, “ensure that the momentum and support that has grown around collaborative working and the transformation agenda is not lost as services recover from COVID-19 pressures”.5 But how realistic and desirable is this?

On the one hand, the pandemic has in some settings ‘forced’ organisations to work together towards common goals. The NHS confederation rightly suggests that investigation into understanding why some have done so successfully in some areas and not others may yield valuable lessons. These lessons and reflections could provide useful insight into what might be helpful for the establishment of ICSs in the future.

Valuable insights could come in the form of understanding: service boundaries and limitations; issues regarding risk and accountability; capacity and resource planning; staff willingness and preparedness to work collaboratively across services, as well as any professional resistance to doing so and the reasons for this.

The extent to which frontline staff will be able to sustain the level of momentum and indeed the desire needed to support ICS establishment … needs to be questioned.

But this drive to ICSs has to be moderated against the backdrop of what has happened with the pandemic. Community care of all types has had to rapidly change. This change will have profoundly affected the workforce – both front line providers and managers. These are the very individuals who will be expected to facilitate and implement yet more change if ICSs are driven through. Will they have the capacity to do so? For example, for ICSs to be effective, building trust and collaborative relationships are needed and this takes both effort and time. Sustainability may prove difficult if the capacity of individuals to help deliver on ICSs goals is overestimated. The extent to which frontline staff will be able to sustain the level of momentum and indeed the desire needed to support ICS establishment therefore needs to be questioned.

In light of the above, could now be the time to slow the pace of change? Might a headlong rush to implement ICSs erode the trust that those who have to work in and implement ICSs have for those who drive this agenda? We have already mentioned that trust is a key component in the development and success of systems implementation.1–2 Yet when there is such fragility and strain across an entire service, a natural pause in proceedings at this point may over the longer term, create lasting success.

 

References
1. Charles A. Integrated care systems explained: making sense of systems, places and neighbourhoods. London: The King’s Fund, 2020.
2. Timmins N. Leading for integrated care: ‘If you think competition is hard, you should try collaboration’. London: The King’s Fund, 2019.
3. NHS England. Interim NHS People Plan. 2019 https://www.longtermplan.nhs.uk/wp-content/uploads/2019/05/Interim-NHS-People-Plan_June2019.pdf (accessed 17 June 2020).
4. Abrams R, Wong G, Mahtani KR, et al. Delegating home visits in general practice: a realist review on the impact on GP workload and patient care. Br J General Pratice 2020, DOI: https://doi.org/10.3399/bjgp20X710153.
5. Pett W. STPs: One year to go? London: NHS Confederation, 2020.

Competing interests
Geoff Wong is a Deputy Chair of the United Kingdom’s National Institute of Health Research.

Featured photo by Timo Volz on Unsplash