Early 2020 saw a number of Cabinet Office blogs on systems thinking as a better way to serve citizens. A ‘whole-system thinking’ approach is key to the NHS England and NHS Improvement (NHSEI) proposals on integrated care systems (ICS). ICS should not be just new NHS bodies, but partnerships between NHS bodies, local government and others to deliver a joined-up approach to commissioning and delivering care.
Systems thinking is set to be pervasive. To be effective, it needs to engage citizens. Local government has the mechanisms and knowledge to ensure place, neighbourhoods and citizens are at the heart of integrated care systems which are responsive to local needs and accountable to communities.
There are many examples where organisational and inter-organisational change programmes imposed ‘from the centre’ or ‘top down’ fail to deliver. In 2015, Nuffield Trust predicted ‘Strengthening local and national democratic scrutiny will be even more important if integrated care develops as planned’. The paper acknowledges the role of health and wellbeing boards, but suggested more was needed, with a key role falling to local authorities and their members. Systems thinking requires broad insight into regional context, including the wide range of factors which may affect or be affected by the system.
The Local Government Association (LGA) has observed that for the ICS programme to fully deliver on its promises it must not simply be ‘a delegation of functions within a tight framework determined at the national level’. Clear governance structures delivered by local authorities can enhance representation of local people, and provide officers with routes to engage in an ICS.
An article in the Health Service Journal last March said: ‘The challenge, however, is that much of what makes us healthy lies outside of the NHS’s immediate reach of our built environment, transport systems, housing, income and so on. Yet the funding that traditionally supports many of these areas has been repeatedly cut…’ This highlights the fundamentally important role of local government in delivery of ICS.
However, the suggestion by the LGA that decisions should be made at local authority footprint level leads to the question: which one? Districts, boroughs and counties with different boundaries will have to present a united front for their area, or risk accusations of being uncoordinated and too busy gazing inwards. At worst, the boat may sail while this is taking place.
Local authorities are rightly proud of the role they have always played in improving the health of an area, from high quality housing and job creation to being at the front of the queue to spot problems within families that may lead to poor health. These roles sit at all tiers of local government but must be presented as a well-coordinated system.
Simon Bottery of the King’s Fund recently observed: ‘When it comes to…social care reform…the sector does not speak to government with one voice.’ He went on to say a lack of one clear voice for the sector made it harder for Government to understand priorities or to arrive at solutions likely to receive support.
The potential impact of one voice, at a regional and national level was evident during the coronavirus pandemic. The most effective voices were often those acting as a systems leader, rather than simply focusing on delivery of their services, and citizens benefitted enormously.
This approach, of crossing boundaries to explore, assess and establish desired system outcomes is inspiring. So is the ability of a systems approach to debunk myths, find new connections and imagine new solutions.
Any complex problem has multiple solutions, but the kind of systems we need to build for health and care, must be related to region and place. There is the scope and need for a diversity of solutions to meet local priorities and needs.
As devolution creates new opportunities for regional uniqueness to be embraced and reflected by strategy, we look forward to seeing how local government rises to the challenges and what it can deliver that further embeds it as a key player in a larger system.
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