Integrated Care Systems (ICSs) are set to move onto a statutory footing in July. But a new report reveals that serious problems are holding back the ability of councils to take on a leadership and coordination role within this new landscape.
Improving long term outcomes in communities will require a step change in the role local authorities play within local health systems, according to the paper published by the LGiU this week,
It has highlighted huge potential for system wide partnerships, especially in the wake of the pandemic. And working effectively across systems is also going to become even more crucial once all 42 ICSs – the partnerships between the organisations that meet health and care needs across an area – become statutory.
But while the report has said councils are best placed to bring coordination to local health systems, it has concluded that ‘chronic issues around funding and capacity hamper the efforts of local authorities to act as leaders’.
The report, sponsored by Browne Jacobson, is based on interviews with council officers in three areas of England. It underlined that systems thinking can help people and organisations to see the overall patterns, structures and cycles in systems, rather than their own narrow responsibilities.
It found ‘widespread appreciation of the value of system-based policy, of partnerships, risk taking and innovation’, but that these ‘often do not play out in practice’.
So what are the blockages stopping the adoption of system thinking? According to Local Health Systems: Relationships not structures, some of the key barriers that have held back progress towards greater integration across systems include:
- A culture of risk aversion among many in leadership positions
- A chronic shortage of capacity within local government
- A broken funding system for councils
- Institutional disconnect between agencies involved in health and wellbeing
The paper argues that moving away from a risk aversion culture and short-term approaches to policy problems requires ‘the debate to abandon the fixation on structure’ and instead focus on two important factors.
The first is leadership that enables coordination across local health systems. Local authorities and other public agencies as well as new Integrated Care Partnerships need to ‘front up to the challenge and provide this system wide leadership’.
The second factor is funding, with the English model for funding local government branded as ‘woefully inadequate and a consistent barrier to strategic action that improves health outcomes across different regions’. And it’s not just a question of there not being enough money available. What’s needed is a shift away from the ad hoc, ‘short term patchwork of ring-fenced pots that Whitehall makes available to councils for capital spending’.
Stability and capacity are needed for strategic planning for health, the report added. ‘It cannot be done on a shoestring.’
So how can change in those two key areas be supported? There are a number of recommendations (see box), including a focus on aligning the strategic documents of all partners, coordinating strategic priorities across the system through system-wide budgeting, and building capacity for system change.
What barriers make it harder for local government to play a strategic role within systems? The report highlights a list of those, including skills, organisational cultures and behaviours, and limited powers for sharing and assessing data. These factors and others are echoed in interviews with 10 policy officers from local authorities in Essex, Lincolnshire and the West Midlands.
The pandemic has had a ‘huge impact on how councils perceive health and wellbeing, as well as relationships with the community’, but the report highlights the risks of old ways of working returning in some places. A senior public health officer in the West Midlands said ‘the pandemic has shown that services are an incredibly important part of this wellbeing’. They argued that this should change councils’ approaches permanently, asking ‘why could I do this systems stuff then, during the pandemic, but not now?’
But the pandemic has increased the proactive focus on changing outcomes, said an officer from Lincolnshire. They have regular meetings with the voluntary sector now and are ‘very aware of the impact of pandemic and government policies on people’. The council has gathered inequality data into one place so they can assess where there are pinch points across the district and better understand the links between deprivation and services such as end of life care.
Funding, capacity and institutional disconnects emerged as the main barriers preventing a more widespread and strategic systems focus with the public sector. On finance, one interviewee from Essex said: ‘Government funding streams are a barrier, they don’t allow themselves to be used strategically.’
On lack of capacity, the officer from an Essex district said: ‘Councils are too cash-strapped to think strategically, though this is probably easier in larger metropolitan areas. We just don’t have the resources and we can’t afford strategy officers.’ Another officer, from the East Midlands, said: ‘If we had more resources we would look at all systems but [are] not able to’.
The differences in structure and culture can be a significant barrier to developing a system-wide approach, said the paper. The NHS plays a leading role in health systems, but as one strategic director from an Essex district said: ‘I’ve never had the sense that the NHS has been open to systems conversations’.
The policy officer from a Lincolnshire district said: ‘Data sharing is difficult, and organisations think they can’t share data.’
On attitudes to risk taking, a senior public health officer in the West Midlands said system-wide working ‘needs a jump of risk, as part of a partnership’ and argued that it ‘requires political appetite so that even when something is not working we try again and take a different approach’.
The importance of ‘honest and high-trust relationships’ was the strongest and most consistent theme from the research. An officer in an Essex district described some of the differences that have taken shape in their council’s culture: ‘In traditional partnerships the person who organises or convenes usually takes away the bulk of responsibilities or actions. In our partnerships we have dispersed leadership, so the responsibility and action is shared.’
Responding to the report , chief executive of the LGiU Jonathan Carr-West said: ‘Good local health systems depend on relationships of trust, transparency and cooperation. Yet the focus of systems thinking is often structures and processes, rather than people and relationships.
‘To move forward on this agenda, leaders need to provide the right framework and incentives for staff to innovate. New approaches and collaborations can entail risks that things won’t work and we need to create the conditions for trust and collaboration, aligning incentives and performance indicators accordingly so that staff feel safe enough to look around them, taking a system-wide view of the work that they do.’
With capacity ‘already stretched in local government and in the NHS’, he said it was time to ‘provide decent, sustainable funding for local government’.
He added: ‘Additional responsibilities for long-term strategy and partnership building should not impose greater demand on local authorities without proper support.
‘Ultimately, devolution and levelling up will only be meaningful if local government is enabled to develop its capacity and given the support it needs to lead locally.’
It is clear that there are huge challenges, but the report does offer some early grounds for hope that a systems focus is starting to shift behaviour and relationships. And in one area at least it is helping to tackle the problem of capacity. As a public health officer in Essex said: ‘The systems approach means that we can work both hyper-locally and bring the county into discussions, maximising the capacity.’
Make sure that all partners’ strategic documents are aligned across the system. Strategic priorities and the documents that are set out to govern how organisations collaborate are crucial.
Work closely with citizens. The shift from structures to relationships should go hand in hand with a shift from services to people. The population should be the starting point.
Balance risk. It is important for commissioners to develop the right balance between risk aversion and risk acceptance.
Create the conditions for behaviour change. Local authorities and other organisations need to create the conditions for trust and collaboration, aligning incentives and performance indicators accordingly so that staff feel safe enough to look around them, taking a system-wide view of the work they do.
System-wide budgeting. Funding should be provided specifically for the coordination of strategic priorities across the system. Various models of single pot place-based financing, going back to Total Place, have been tried and shown to have positive impacts.
Build capacity. Capacity is already stretched in local government and in the NHS. Additional responsibilities for long-term strategy and partnership building should not impose greater demand on local authorities without decent and reliable support.