Creating the conditions for integrated systems of care: Learning from two large-scale approaches to changing thinking, practice and behaviour in Scotland and North West England

Abstract

Introduction: Scotland has an established history of collaborative working across health and social care, and introduced a landmark reform to integrate health and social care services in April 2016. Effectively integrating care in complex health and care environments exposes design, implementation and sustainability challenges.[i],[ii] The Advancing Quality Alliance (AQuA) has extensive experience of implementing national integration policy[iii] at system, service and team level in North West England and elsewhere in UK. Our collective experience[iv],[v],vi indicates that energy is often directed to what is intended e.g. the new model of care, rather than how it can be implemented and sustained. Investment in creating the conditions to underpin an integrated system is crucial to success, yet this step is often omitted or addressed too late. Aim and theory of change: Our shared aim is to develop local capability to integrate care and improve population health outcomes. In order to create the receptive context for improvement work in the integrated environment, our theory is that we need to take a blended approach including complexity science; system leadership; improvement science; change management; organisational development and acquisition of technical skills including partnership working between professionals and patients. Practice change: Based on our practical experiences of working with a number of leadership groups, we suggest three components that build the change conditions for effective system integration and will illustrate each component with practical work undertaken by NHS Scotland and AQuA. i. Change thinking: this applies to new care models, the concept of place, who delivers care and for what purpose. ii. Change practice: this applies to how we work together at the top of our license, partnering with local people to enable self-management and wellbeing; recognising local assets and moving to a community rather than hospital based model of care. iii. Change behaviours: the relational aspects of change are consistently under-estimated and both NHS Scotland and AQuA have created opportunities for stakeholders to meet, share and learn. Individual and team coaching of the Board and top-team ‘sponsors’ has reinforced system leadership theory and role modelling of collaborative leadership behaviour. Timeline, targeted population and stakeholders: Over the last 5-10 years NHS Scotland and AQuA have worked with individuals, teams and multi-agency boards and leadership groups to integrate care for local people. Highlights and lessons learned: We will: i. share lessons learned about the content and form of our extensive range of leadership and change management support and ii. reflect upon and discuss the organisational and system responsibility for creating a receptive context and organising infrastructure through which to co-ordinate development and meet the needs of change leaders at different times. Sustainability, transferability and conclusions: Both NHS Scotland and AQuA have spread their work to new teams and locations and have found that paying attention to thinking, practice and behaviour is a useful framework on which to build the conditions for sustainable change. Transferability and sustainability are dependent upon local context and whatever the setting, an equal focus on the plan (what) and implementation (how) is crucial to successful adoption.