Integrated Care Systems (ICSs) will need to think more about people than legislation

There is a tendency in healthcare strategy to focus on the structures and organisational constructs of healthcare rather than the behavioral and emotional processes that are responsible for delivery. This over reliance on anatomy is unfortunate as it is often in the physiology of complex adaptive systems where the hidden opportunities and risks reside. 

This is certainly true of the current pivot towards whole system thinking and integrated care. This critically important step for healthcare is long overdue and the recent white paper from the UK government around the reorganisation of the NHS into about 44 integrated care systems (ICSs) is a great opportunity to focus the NHS on populations rather than organisations. However, it is unlikely to deliver its full potential if we overly concentrate on the rules and structures that statute will define. It is more important to understand what this means for the actors in the system and how they will be expected to think, feel and behave. How will we get the organisations in the NHS to play nicely together when we have encouraged and rewarded the opposite behaviour for so long.  There is an argument that if we take a more humane view of this health policy, it is more likely to be successful. The celebrated economist Elinor Ostrum described it brilliantly: 

‘Designing institutions to force self-interested individuals to achieve better outcomes has been the major goal posited by policy analysts for governments to accomplish for much of the past half century. Extensive empirical research leads me to argue that instead, a core goal of public policy should be to facilitate the development of institutions that bring out the best in humans.’

To take a more humane lens to understand this human condition better it is worth viewing these ICS reforms as a collective action problem. This is defined as a situation in which all individuals would be better off cooperating but fail to do so because of conflicting interests between individuals that discourage joint action. Imagine a locality that wants its GPs to all use the same electronic health record system.  It is self-evident that the whole system would be better off with that level of standardisation but inevitably some practices will have to go through some hardship to change. This is a common dilemma in digital healthcare and one we need to get more sophisticated in addressing.  Sociologists teach us that to be successful there are three approaches to a collective action problem:

·       Government regulation: We will see this with ICS legislation where laws are passed to declare it against the law to act selfishly and require organisations to cooperate.

·       Foster ownership: If people are invested in something, they will work together to realise its collective benefits. 

·       Self-determination: Giving people local decision-making powers creates a tendency to cooperate rather than kick against externally imposed changes. 

I think there are important lessons here in all aspects of our ICS journey whether that be service development, digital transformation, estates reconfiguration or workforce strategy. 

Fostering ownership It will be important ant that we think about and measure the factors that determine whether a sense of ownership is sufficiently authentic to impact behaviour.  Perhaps the two most important ones are scale and transparency. There is a reason that PCNs cover 30 to 50 thousand people as this models to roughly 150 healthcare professionals, the much lauded Dunbar number. This figure is claimed to be the maximum number of ‘trusted relationships’ humans and indeed primates can hold. We have the National Association of Primary Care to thank for that inspired bit of design. It is a testimony to the fact that the basic currency of healthcare is trust. Both for relationships between the public and the professionals but also between the professionals themselves. I believe we can still create a sense of ownership at the size of ‘place’ and ‘ICS’ but we need to be realistic these will be different. 

Self-determination There are important opportunities here too. The creation of systems from the bottom up, which often means clinically led but certainly business led. Imagine the power of all the surgical theatre managers in an ICS discussing the design priorities for theatre utilisation systems and the opportunities for ICS scale ‘load sharing’. Look at the success of primary care IT systems as an example of what can be achieved when people are empowered to find or create solutions for themselves. For self-determination to feel real it has to start small and build incrementally, iterating as you go, identifying quickly when things aren’t working and changing tack. In many ways it is the process undertaken rather the final decisions that make most difference for the actors to feel in charge. In this context it is key to get an early return on investment - an early win for those involved, either clinically, financially or in terms of operational efficiency. We need to learn the risks of not connecting the ‘pain and the gain’ of system design. The emerging discipline of user centred design has a lot to offer here and is something we need to make more of in healthcare. 

Integrated Care Systems will hopefully be a major step towards creating a more humane NHS that puts people at the centre, both patients and staff but we need to remember its more about motivation than legislation. 

https://www.gov.uk/government/publications/working-together-to-improve-health-and-social-care-for-all/integration-and-innovation-working-together-to-improve-health-and-social-care-for-all-html-version

Dunbar, Robin (1998). Grooming, gossip, and the evolution of language (1st Harvard University Press paperback ed.). Cambridge, Massachusetts: Harvard University Press. p. 77. ISBN 978-0674363366. Retrieved 17 December 2016.

https://napc.co.uk/wp-content/uploads/2018/06/Provision-of-integrated-care.pdf