Designed correctly, Integrated Care Systems (ICSs) should deliver care more responsively and effectively than anything to date. By harnessing the latest digital, policy, and organisational advances, with reformed payment mechanisms, ICSs promise better population health across the health-social, primary-secondary and mental-physical care divides.<\/p>\n
As always, people are at the heart of the vision: citizens and communities, patients and families, clinical staff and leaders. To work for all, ICSs must focus on the journey each person makes, within a framework of policy, finance and governance.<\/p>\n
ICSs are a response to now widely recognised failures in UK health and care delivery but are new to the NHS and are themselves subject to unfamiliar mechanisms of failure as well as success. In this article, we explore four challenges to integrated care \u2013 dynamics, delivery, design, and alignment \u2013 and recommend a new approach to system transformation.<\/p>\n
Effective performance as a dynamic, integrated, system is radically different from the workings of the pseudo \u2018internal market\u2019 \u2013 with \u2018transactional\u2019 characteristics that have defined the last three decades of health and care delivery. It requires a change in mindset, new approaches, guidelines and procedures.<\/p>\n
Furthermore, striving for \u2018total connectivity\u2019 means that small glitches can generate avalanches of knock-on effects. As systems become more integrated, the firebreaks of traditional provision disappear, and problems can spread further and faster. This means that ICSs must exhibit extreme resilience as they develop.<\/p>\n
The second challenge is in how to adapt what we have already learned from radically re-aligning payment methods with outcomes, and incentivise effective collaboration. NICE (The National Institute for Health and Clinical Excellence) has pioneered value-based policy since 1999, making the UK a global leader. An example would be best practice tariffs informed by NICE guidance (for instance in care for heart failure<\/a>). However, value-for-money does not guarantee affordability within a departmental, local, regional, or annual budget (see Young & Mallender, 2020, Aligning value and incentives to make digital health really work<\/a><\/em>, ICJ), so fresh thinking and new ways of working are needed. But this ambitious goal is well worth pursuing.<\/p>\n While we are born with billions of neurons \u2013 grown in months \u2013 a brain takes decades to mature because it relies on interconnections, not just functioning units. Similarly, the ICS building blocks \u2013 clinics, theatres, equipment \u2013 can be built quickly today, but planning the connections between them takes much longer than it used to, while end-users absolutely must be involved from the outset.<\/p>\n This means that the balance between the planning and implementation of care shifts radically. A new mind-set must feel safe with longer planning and design cycles, more concurrency (where very different challenges are addressed together), all underpinned by more agile, adaptive commissioning.<\/p>\n Finally, all ICS partners must align policy and operations across the whole system, including: policies to address variations in the wider determinants of health; operating public health programmes at scale; and providing integrated personalised care and treatment. The science of personalised medicine is well understood but the logistics are new and population health management requires tools that we are still only learning how to use.<\/p>\n The key things to focus on when designing an ICS are:<\/p>\n Leaders and policymakers will need expertise that is better networked to reach deep knowledge in consensual ways that combines wider skills.<\/p>\n There are no shortcuts for fostering systems as complex and big as ICSs, so look for flexible support that can switch from strategy to technology, to organisational development, to finance, to clinical flows, to resource management, and can be sustained for the duration of development. Experienced hands \u2013 but with the curiosity and appetite for the new era \u2013 will be hugely valuable.<\/p>\n Don\u2019t forget, our collective intuition has been honed in very different systems, so grill your experts with care before taking them on: you are looking for experience, agility and a wide range of skills, tools and capability.<\/p>\n If comprehensive system transformation is achieved, then providers and policymakers alike can share a wonderful sense of fulfilment, safe in the knowledge that they have created a solid foundation for integration to thrive throughout their system of health and care.<\/p>\n Jacque Mallender<\/strong>, Director of Economics by Design<\/a>. jacx@economicsbydesign.com<\/a><\/p>\n Jacque is an Economist and co-founder at Economics by Design. She is a respected international health and public policy economist and health evaluation practitioner. Over the last 35 years, Jacque has worked across health and social care with a focus on evaluation and health economics in UK, Europe, North America and more recently the Middle East and North Africa. She was a founding convenor of the joint Campbell and Cochrane Economics Methods Group and for 15 years was a committee member. In addition to her work at Economics By Design, Jacque is a Member of the Executive Committee of the Economic Research Council and an Associate of the Oxford Centre for Triple Value Healthcare.<\/p>\n Alastair Mitchell-Baker<\/strong>, Director of Tricordant<\/a>. alastair@tricordant.com<\/a><\/p>\n Alastair enjoys working with a diverse range of clients as a consultant \u2013 from NHS and councils to international NGOs, government departments and global companies, in the areas of organisation design and development, strategy and systems and leadership development. He has also worked in NHS senior management including as a Chief Executive and a Non-Executive Director. He was co-founder of the European Organisation Design Forum.<\/p>\n Clare Morris<\/strong>, Director of RETHINK Partners<\/a>. clare@rethinkpartners.co.uk<\/a><\/p>\n Clare Morris founded Rethink Partners after a career in senior health management in the NHS. She has significant experience of delivering integration across health and social care systems with a strong interest in community health, mental health, learning disabilities, children\u2019s services and neurodiversity. Having delivered big changes as an NHS leader, Clare now works with others \u2013 at all levels \u2013 to make change happen and create the conditions in which integration can thrive.<\/p>\n Professor Terry Young<\/strong>, Director of Datchet Consulting<\/a>. terry@datchet.consulting<\/a><\/p>\n Terry worked in industrial R&D before becoming an academic and is now Director of Datchet Consulting. With over 30 years’ experience in technology development and strategy, health systems, and methods to ensure value for money, his current focus lies in designing services using computer models and he set up the Cumberland Initiative to support healthcare organisations wishing to develop their services more systematically.<\/p>\n
\nDesign<\/h3>\n
\nAlignment<\/h3>\n
\nLooking forward<\/h3>\n
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\nContributors<\/h3>\n