The NHS needs more leaders who ‘think in systems’
By Dr Parth Patel8 October 2021
The NHS needs more leaders who ‘think in systems’ | Comment | Health Service Journal
The NHS needs more leaders who ‘think in systems’
By Dr Parth Patel8 October 2021
For all the welcome aspects of the Health and Care Bill, it is culture, not structure, that ultimately determines the quality of health system integration, writes Dr Parth Patel
The NHS faces one of its toughest ever winters, with record-long waiting lists, an ongoing pandemic and an expected surge in flu and other respiratory illnesses. Waiting lists will continue to grow for months – perhaps even years – to come. Given the challenges and uncertainty ahead, the timing of the integrated care system reforms are a political gamble.
But it’s a gamble that could pay off. High quality integrated working between different parts of the health and care system can, in theory, improve outcomes, reduce inequality and save money. That is no easy task – improving health system integration has been a policy goal for decades, but achieving it has proven difficult.
If greater integration is the objective, then it’s important to recognise that different places have wildly different starting points. New analysis from IPPR and CF healthcare has found considerable variation in the quality and outcomes of integrated care between ICSs.
There are nine times as many delayed discharges, where patients are left stuck in hospital, in Norfolk and Waveney ICS compared to Sussex and East Surrey ICS. Mental health patients with severe problems in Bath, Northeast Somerset and Swindon and Wiltshire ICS are three times more likely to have a care coordinator than those in the Leicestershire region.
Each ICS is facing a unique set of challenges. That means it is critical they are empowered to set their own local health priorities. And it is critical those starting from further back have the support and resources they need to improve outcomes for patients and communities in their patch.
Whether ICSs simply reiterate existing inequalities in new geographies, or become the vehicle for a step change in patient and population health outcomes, will depend on more than legislative change. For all the welcome aspects of the Health and Care Bill, it is culture, not structure, that ultimately determines the quality of health system integration.
Place-based relationships are the essence of collaboration and flourish when commissioning encourages local institutions to work together. IPPR is recommending a ‘community health building’ approach to both ICSs and the government, inspired by the community wealth building movement that has been implemented by councils like Preston City and Newham.
ICSs should use their sizeable budgets to not just commission the best health services, but to ensure commissioning choices also create high quality local jobs, support community organisations and local businesses, and drive local economic growth.
To go alongside the physical-infrastructure focussed Levelling Up Fund, the government should announce a Community Health-Building Fund for local authorities to invest in social infrastructure.
Successful integration also relies on leadership being well distributed across the health and care system, rather than concentrated in any one part. Too often it is acute hospital trust executives that yield greater power than those in primary care, community care and local government
Successful integration also relies on leadership being well distributed across the health and care system, rather than concentrated in any one part. Too often it is acute hospital trust executives that yield greater power than those in primary care, community care and local government. ICSs must spark a move away from this power dynamic and toward new ways of working.
Currently, there are simply not enough leaders who ‘think in systems’ in the health sector. National NHS leadership development programmes have proliferated in recent years, but they overlook the importance of local geography and formal exchange with institutions outside of the NHS.
ICSs should create their own leadership development programmes that move current and future leaders through the place-based health, housing, education, police, community and voluntary organisations to develop a deep and local understanding of what makes integration work. This kind of knowledge exchange not only develops leadership but also builds the foundations for relationships that define integrated working.
To ensure these reforms deliver, people and communities need better ways to hold the health service to account. More taxpayer money is spent on health than any other public service and past reforms have failed to deliver improvements for patients, yet only weak mechanisms exist for elected officials and citizens to hold the health service to account.
The government’s language to “improve accountability and enhance public confidence” is therefore welcome and necessary. But it is not clear how proposals to give the secretary of state more directive powers over the health services would strengthen democratic accountability.
Indeed, they may bypass the benefits of devolution promised by the ICS reforms. It would be better to give local authorities and citizens a more pronounced role.
That could include ensuring patients are represented on ICS boards and, instead of ‘tick-box patient engagement’ exercises, wiring citizen panels into ICS decision making, for example when difficult trade-offs under resource constraints are being made.
In the end, the ICS reforms should be judged on whether they improve outcomes for patients and communities. IPPR and CF have estimated that if all ICSs eventually match the outcomes already seen in the top 25 per cent it could mean 42,500 more bed days available in the NHS because of fewer delayed discharges, an extra 63,000 people would have a mental healthcare plan and there could be 68,000 fewer accident and emergency attendances by people with mental health problems.
To achieve that, we’ll need a lot more than a new bill. The government’s forthcoming white paper should focus on creating a culture of collaboration to solve the integration puzzle.
London
Systems Community of Inquiry 
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