How do we grasp a nettle like integrated care?

We need more than Patient/Customer centred design

I spoke to a despondent NHS Programme manager recently who had just presented two months of detailed planning to her STP Board on a revised Intermediate Care Pathway.

They had been enthusiastic initially but when detailed changes were presented, each was challenged, despite the evidence for improvements, and there was no clear commitment from the board to progress except to return to the topic at a future meeting.

What my colleague missed was the unstated incentives in the room.


The thoughts of the board members might sound like this:

Director of Adult Social Care : “I’ve seen far too many of these efforts fail in the past and I can’t justify scarce time and resources when it’s not one of the Lead Member’s priorities.”

The Acute Trust Director: “This will create more work for my Discharge team which is already overstretched and has just been restructured.  It would be a challenge to repeat the difficult discussions on increased funding needed from the iBCF.”

The Community Trust Director: “These plans will cut across the changes we’re rolling out in our District Nursing team which have to take priority this year.”


Such thoughts often remain unspoken because senior leaders correctly prioritise building and maintaining working relationships and are skilled at managing the often-irreconcilable demands placed on them and their teams.

This leaves a lot of local care systems falling short of their potential despite the committed and experienced public servants who work in them.


You don’t solve a complex problem within the frame in which it’s created

If we are ever to break this logjam, we must start with the patient and customer in mind and get very clear locally about an enduring definition of good pathway outcomes.  If we make repeated changes based on shifting priorities to reduce Intermediate Care costs, Delayed Transfers, residential admissions, or acute readmissions we will of course end up with an incoherent system.  They are all valid requirements and must be considered together.

My plea is that we also take as much time to understand and address the competing incentives and priorities of partners across the health and care system, otherwise we get no further than stalled planning or partial implementation at best.


There is no silver bullet

Building pathways that work for all stakeholders is not easy.  In addition to clear outcomes and a solid evidence base, a significant investment of scarce time is needed to uncover and understand competing priorities.  Skills around innovation, coaching and negotiation are needed to develop and agree the way forward.  We must also build trust through small-scale change done well if we are to deliver our long-term visions and acknowledge local funding constraints on the scale of our ambition.


Funding and structural changes from central government may have their role to play in such change but will not deliver on their own.  At a local level, if we always do what we have always done, we will always get what we have always got and in an increasingly integrated system we may prefer to explore more effective ways of working together.

This article was written by Bill Guthrie