“Trust” - the Currency of Integrated Care

David Harrison - Chairman, Anglian Community Enterprise

Buried deep in the Long Term Plan is the NHS’s ambition to develop an “Integration Index”. This will test the extent to which health and well-being partners are providing joined-up care. 

This is a fascinating, if mightily unformed, concept. Rather like the FTSE 100 measures the fluctuating value of shares, the Integration Index will be a single metric for measuring the quality of collaboration in the NHS.

But if we have an Index, we must have a currency – after all, without a currency, we‘ve no way of storing value generated today into tomorrow.

A stable currency permits people to exchange goods and services in a consistent and predictable way. Conversely, a volatile currency brings uncertainty, often leading to prevarication and delay, whilst a falling currency brings panic and distress.

The currency of integrated care is trust. Strong and stable currency conditions lead to joined-up planning, co-ordinated service delivery, joint problem-solving and cross-collateralisation of risk. In other words, if trust is flying high, the Integration Index soars!

A loss of trust leads to devaluation. Appetite to work in a joined-up fashion plummets, problems aren’t solved, but land in the laps of others, and risks aren’t managed, they’re studiously avoided. The Integration Index crashes!

In my recent experience of ICSs, I’ve seen two significant currency exchanges in operation. In both, the value and volatility of the currency is set, and continuously re-set.

The first currency exchange is the ICS Partnership Board (or its equivalent at “place” level) - this is the “business lounge” of collaboration.

Board members come together to commit to collaborative working; they identify some 1st order priorities whose achievement will threaten no-one; they commit funding that was never theirs, and they dedicate resource that someone else is paying for.

When it next meets, the Board checks its priorities are on-track, that no major damage has been done to any one partner, and then celebrates the Integration Index hitting new heights.

This process reminds of what “business-sage” Mike Tyson once said about the value of “planning” – “everyone has a plan until I smash them in the face”. Same with the Partnership Board; trust remains high until “someone gets smashed in the face”.

The currency of integrated care isn’t “smelted” and “smithed” in the Partnership Board. This happens where partners are working together, on the ground, to “transact” radical service change. The true value of the currency is struck in this “bear-pit”, not in the “business lounge”.

Every ICS worth its salt needs to have its own “bear-pit”. The collaborative challenge thrown into this arena must have hard deadlines, and compelling incentives, to force the pace of change.

In our ICS, we used the shift to a new Urgent Treatment Service (UTS) model as our first collaboration “bear-pit”. On top of the pressure to meet new, national standards, all service contracts come to an end in March 2019.

The UTS is a multi-partner service (involving primary, community and voluntary services). It also has major co-dependencies with services such as ambulance, 111/OOH and the acute hospital.

On launching our redesign work, the “world and his wife” wanted a say on the future of the UTS. However, as our service, operating, commercial and contract models developed, trust was built and workable arrangements emerged.

An open debate about the nature of our UTS collaboration played a crucial role - we dubbed this the “thick or thin” question.

A “thick” collaboration involves joint oversight and joint supervision, collective decision making, combined continuous improvement, co-investment and financial risk-sharing, codified in a legally binding Collaboration Agreement. A “thin” collaboration highlights the benefits of working together but, contractually, creates only light-touch co-operation obligations. We opted for a “thick” collaboration.

The risk-pooling feature of the “thick” model forced partners to rapidly differentiate themselves into “full” and “associate” members of the UTS Collaboration. Full members share risk and control, associate members participate and influence. Involvement in such an open process gave other partners confidence to enter into sub-contracting arrangements with full members, assured that institutional interests would be fairly taken into account.

This process has taken time and effort; much more than we had anticipated. However, this newly-minted currency looks strong and stable, and can now be applied when transacting further multi-lateral change.

Our local Partnership Board is also now intrigued about how it can capitalise on the rising value of our local currency, brokered in the “bear-pit”. After all, it’s only right that, at their next meeting, those in the “business lounge” get to chink their glasses to another rise in the Integration Index!

 

Dr Niamh Lennox-Chhugani - Healthcare Lead, EMEA, Optimity Advisors

David has quite rightly identified trust as the currency that is exchanged in systems or networks which collaborate. Whenever I have been speaking to senior leaders about collaboration in integrated care systems in England and other countries across Europe, trust repeatedly comes up as an essential system attribute. The trust that is often missing in systems is not between leaders or even between those at the front line but between leaders and their own frontline. Looking at the successful models of integrated care across Europe, our study found that those where the ”bear pit” is genuinely trusted by their leadership and given permission to collaborate for defined value are the most successful in delivering change. The Buurztorg model in the Netherlands is an oft cited example of self-managed teams and is being replicated in the UK and US now. It may seem obvious but trust and trustworthiness is only increased with time and practice. The job of the “business lounge” is to provide the “bear pit” with that time and opportunity to practice by taking a leap of faith and trusting the frontline to do the right thing.

 

David Harrison

David Harrison

ABOUT

David has worked extensively in the public and private sectors. He is a qualified chartered accountant and spent some years in investment banking before joining the public sector in the 1990s. Here he became a senior civil servant (Dept of Health and HM Treasury) and, for 11 years from 1999, led the health practice of Partnerships UK.

David has worked at the policy level in government and as part of the regulatory apparatus in the public sector. He has also undertaken and led detailed, complex and prolonged commercial negotiations on behalf of government and public bodies, managing multi-disciplinary teams, comprising both public and private sector personnel, in strategic change programmes, in PPPs in public service outsourcing and in public:public and public:private co-venturing arrangements.

In recent years, David has provided market design and development advice to NHS England in respect of commissioning management (and informatics) support. David has also provided programme direction and integration advice to one of England’s 1st wave ICSs.

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