Systems: challenges and opportunities

In this section we consider the introduction of integrated care systems (ICSs) and the challenges for systems, particularly around inclusivity and planning and their importance for people living in their local areas.

From our own work looking at care within the emerging and newly established systems, and from listening to people’s experiences of care, we can point to some areas of focus for local systems as well as some tangible collaborations that are already making a positive difference in people’s lives. The areas for focus include:

• leadership in establishing collaborative local relationships
• ensuring all local services are included in planning how to keep people well
• understanding local population needs to improve planning and address inequalities.

Integrated care systems and CQC’s role

When the Health and Care Act 2022 formally established integrated care boards (ICBs) to deliver system-wide strategic plans for the delivery of health and care services across local areas, it also provided a new role for CQC to review and assess the integrated care systems associated with each ICB. This will start in April 2023.

The introduction of ICSs instigates a change in the focus for our regulation and how we consider the quality of care, including how well systems are integrated to serve local people.

We already know about some factors that have an impact on the quality of care people receive, especially in what we see at individual service level. We need to better understand what affects people’s experience of care, so we are transforming the way we work so we can do our best to ensure people receive safe and high-quality care.

We will be better equipped to shine a light on good or poor quality of care – and to understand the causes of poor care by looking at what’s happening under the surface of local care systems. We have progressed to a position where we can start to realise two of our strategic ambitions:

• providing independent assurance to the public about the quality of care in their area
• tackling inequalities in health and care by pushing for equality of access, experiences and outcomes from health and social care services.

There are many challenges facing the leaders on the ICBs. From our previous work across local systems, we know that better outcomes are possible for people in places where system leaders work well together. We know this particularly from our work across different places and where we have looked at services for older people. Also, we saw this in our November 2021 report about services for children and young people with mental health problems.

Challenges for systems

Achieving integrated care is a new responsibility for all organisations charged with delivering health and social care services. Until now, services have operated in autonomous ways – for example, GP practices with their own financial arrangements, NHS trusts with their own workforces, or social care services operating across their own defined localities.

This has meant people do not always get high-quality care or a good experience when they use services – especially if they need multiple services.

While CQC’s focus remains the quality and safety of services, and the experience of people when they get care, we will now also be looking at the leadership in ICSs and assessing how well services are integrated.

The inception of ICSs and their respective ICBs comes at a time when providers are reeling from the impacts of the pandemic, but they also face problems in health and social care that pre-date COVID-19.

In the mix of challenges for the new systems, reports have described how the country ‘entered the pandemic in a vulnerable position’. In November 2021, the Health Foundation described “systemic weakness in the NHS and poor underlying health”, pointing to a system with “fewer doctors, nurses, beds and scanners relative to European neighbours”. Nuffield Trust said in September 2022 that historical trends in key performance measures “paint a picture of a system already stretched beyond its limits before the pandemic, with access and waiting times in a gradual but steady decline”.

In August 2022, NHS England (NHSE) published guidance about the winter ahead, also detailing 6 metrics for accountability in the performance of ICSs. They point out that its elective recovery plan is underpinned by the new approach to how organisations in the NHS work together. NHSE and ICBs will be monitoring:

• 111 call abandonment
• mean 999 call answering times
• Category 2 ambulance response times
• average hours lost to ambulance handover delays per day
• adult general and acute type 1 bed occupancy (adjusted for void beds)
• percentage of beds occupied by patients who no longer meet the criteria to reside.

Good leadership is vital

When we have visited some local areas – systems in their infancies, or before they assumed their formal ICS existence – we have found varying degrees of success in the way services were collaborating to improve people’s experience of care. There is some consensus around this, and the various challenges identified for ICSs’ leadership, among independent reports for government and policy experts, including a report by Baroness Cavendish.

The first annual report by the NHS Confederation’s ICS Network has assessed the progress of ICSs and is based on the views of system leaders. They say one of the biggest strengths so far is that 90% of system leaders believe they have been able to improve joint working. However, they warn there is a risk that, without enough time and space, they will not be able to deliver the radical changes to health and care services that the pandemic has demonstrated are needed.

Among the challenges, they say that further support is needed to help systems achieve the ambition of systems contributing to local social and economic development. Also:

• Primary care leaders highlighted that in many areas there is uncertainty about how the experiences and insights of those leading primary care services at neighbourhood level inform system-level planning and strategy.
• System leaders feel the biggest obstacle preventing further progress is national workforce shortages – 3 out of 4 said this was the top priority.

In an independent report for government by General Sir Gordon Messenger and Dame Linda Pollard, some of the immediate tasks for systems’ leadership are laid out for those looking to build a collaborative and inclusive future.

Looking across health and social care, the report described “institutional inadequacy in the way that leadership and management is trained, developed and valued”. It echoes some of our own findings from recent years, particularly the importance of collaborative behaviours.

We have often reported about the importance and impact of good leadership at service provider level and its link to better outcomes for people who need care. The Messenger and Pollard report stressed the importance for systems to show "scollaborative leadership, broader cross-sector awareness and understanding".

The importance of local partnerships

CQC has an important role to play in assessing and supporting providers and systems to improve. We will assess the way multiple health and social care providers work in partnership locally, checking that their focus is on improved experiences and outcomes for people.

The King’s Fund, for example, says it is important to measure and assess the right things – it points to CQC’s role to “evaluate whether the objectives of ICSs – better integration, population health, and prevention – are being met”.

In a briefing published by NHS Providers in August 2022, we can see examples of provider collaboratives that are developing across England and their reported benefits. These collaboratives are partnership arrangements bringing together two or more trusts to maximise economies of scale and improve care for their local populations. NHS Providers points out that NHS England has required all trusts providing acute and/or mental health services, including specialist trusts, to join at least one provider collaborative from July 2022.

NHS Providers points to “unanswered questions and risks for trust boards to navigate” when exploring the opportunities of collaboration at scale. However, they say that trust leaders across all sectors see “potential to improve care and services through driving standardisation, addressing unwarranted variation, bolstering service resilience, identifying approaches to better support people experiencing inequalities, and developing innovative ways of working with other local partners such as social care providers and primary care services”.

From what we have seen in our recent local reviews of urgent and emergency care in local areas – and in previous provider collaboration reviews – the quality of pre-existing relationships between local providers plays a key role in the coordination and delivery of joined-up health and social care services that meet the needs of the local population.

Baroness Cavendish’s February 2022 report points out that the pandemic “prompted a level of positive collaboration”, a view supported by the NHS Confederation in June 2022. However, the Cavendish report goes on to say, “The NHS showed little comprehension of the care sector or its needs… linkages between NHSE and local authorities proved to be virtually non-existent.” She adds that the “lack of parity between the NHS and social care became stark”.

We know that many good local partnerships are making a tangible difference in people’s lives. For example, a homecare service that worked closely with district nurses, a GP and other care professionals made a positive change for a person who lived for years with serious skin problems. Their collaboration, sharing care plans and offering consistency of care, led to an improvement in the person’s skin so that they had many months with no further concerns. The homecare providers’ relationship with their health and social care colleagues was also cemented for the long term.

Some good collaboration was sparked by the pandemic and we know from previous provider collaboration reviews that solid partnerships were founded this way. In some cases, the collaborative approach has continued – in some local areas, we know how system partners met twice a week with a focus on care home needs, including infection control, medicines management and access to GPs. This was effective at managing risks and partners also spread their staff where they were needed most.

The Birmingham and Solihull ICS has increased partnership working, also using ‘mutual aid’ within the system. Beginning during the pandemic, providers worked to ensure staff were moved where the need was greatest, such as intensive care. The partnership has developed further and now includes recruitment campaigns and making sure people are appointed where greatest need is identified.

Across the Herefordshire and Worcestershire ICS, there is a system-wide approach to bank and agency staff – this has helped by setting a pay cap, which means providers are not outbidding one another for new recruits. We know about a similar project involving mental health services in parts of London and Essex.

Some providers are working together to directly address the risks people may face because of current delays in patient handover between services. In the south west, they wanted to reduce the risks for people who might have to remain sitting or lying down, often in an ambulance, while waiting for a possible hospital admission. When a delay like this happens, pressure injuries can develop within an hour or injury is very likely within 4 to 6 hours. Ambulance trolleys were not designed for long waits.

South Western Ambulance Service NHS Foundation Trust’s clinical team has worked with hospitals’ tissue viability specialists across the region to reduce these risks. Their pressure ulcer guideline was updated with an extra focus on care during patient handover delays and a specialised type of mattress was identified that would reduce the risk of ulcers – it helps with pressure redistribution and the mattresses are already stored and used at 4 hospitals, with another 3 hospitals lined up. At another 3 hospitals, arrangements have been made to reduce risks by transferring patients to hospital trolleys if there are extended waits.

Planning and inclusivity

All services working in a local health and social care system should be included in planning for healthier communities. To maintain and develop the required workforce, as well as to plan for the future, providers and systems need to be clear about demands in the longer term, including the required workforce skillsets. A strong understanding of local community needs is needed to ensure the right services, including preventative health measures and plans for improving health outcomes.

In the first year of the pandemic, we saw organisations working together and often rotating some employees’ workplaces. This helped with capacity issues, but it also upskilled some staff. Continuing and developing this model would also help to break down barriers and gain a shared understanding of people’s journeys through the health and social care system.

Recognising the importance of effective social care in a local system, one NHS trust is aiming to help to resolve unmet demand by growing its own homecare provision. Northumbria Healthcare NHS Foundation Trust is an established hospital and community services provider that says it intends to recruit people to 250 jobs – it plans to ”use its expertise to help support the care sector in Northumberland and North Tyneside”.

The plan aims to enable the region’s hospitals to cope with demand from new patients by moving on those patients in hospital who no longer need to be there.

There is a need to expand training and education for new health and social care staff, so that the future workforce has a good awareness and understanding about system plans and new models of care. This will help to change mindsets and ensure professionals focus on people’s care pathways, considering preventative health measures to achieve better health outcomes.

There are different challenges for different sectors to achieve more local inclusivity. With services coming together, a King’s Fund analysis in December 2021 points out that there are challenges – for example, “language, spending power, metrics culture and leadership style”. The King’s Fund points out that adult social care services have “vital experience and understanding” and how to involve them will differ across ICSs. It adds that social care shouldn’t “undersell itself” and notes that “social care and local government have strong history of mobilising assets around the needs of the individual and tackling inequalities”.

The analysis highlights that inclusivity will recognise “who does what best in the system”, pointing out at that social care must be “on the agenda, not just in the room”. This observation was also clear from some of the provider collaboration reviews we carried out in 2020 and 2021, with the potential for partnerships relying on an understanding about collective responsibility around system challenges.

A May 2022 report points to the importance of helping people to stay well for longer. Dr Claire Fuller’s Next steps for integrating primary care: Fuller Stocktake report notes that “improving the experience of accessing primary care is essential” and adds that too often most of the effort “is focused on treating people who have already become sick”. Reporting on the role of primary care in the new ICSs, Dr Fuller says there needs to be a “sense of urgency around providing proactive care and improving outcomes” for people. The report adds that this is “only achievable if we work in partnership” to address inequalities, “taking action to address the wider determinants of health”.

Keeping people well

We have previously reported on examples of good local planning. They are usually examples where services are working hard to address specific localised issues, rather than whole-system planning that is more strategic and considers wider population needs and inequalities.

The Fuller Stocktake report cites positive examples where primary care is part of integrated neighbourhood teams that are trying to improve access for same-day urgent care, recognising that the “current system is not fit for purpose” and that workforce gaps must be confronted. Dr Fuller adds that “a new care model will not magic-away our workforce challenges”.

We have also focused on the importance of systems understanding the needs of their local populations, so they can plan better. There are NHS working groups called ‘Maternity voices partnerships’ (MVPs) and in our review of safety, equity and engagement in maternity services we found some positive examples of targeted engagement with local communities:

• One service was participating in a local maternity system survey, looking at cultural safety in working with women from ethnic minority groups.
• One MVP was working with the local maternity system to recruit diversity champions to build links with local communities.
• Another service, supported by their MVP, was holding weekly focus groups to better understand the issues faced by women from ethnic minority groups.

The focus of our provider collaboration reviews on health inequalities encouraged some systems to think about how they could address these issues in their area. Some systems were not as far along in their thinking as others and our focus had helped systems to consider inequalities as a key topic.

From our survey of more than 4,000 people aged 65 and over who had used health or social care services in the previous 6 months, we know that people in more deprived areas tended to be less positive about their care, as were disabled people and those with long-term mental health conditions. These groups were also less likely than average to be satisfied with being able to access services when they needed them and in a way that suited them.

There is a role for systems in promoting better health. Just over half of the people surveyed who had used health and social care services in the last 6 months (52%) told us they had also accessed the groups or organised activities contributing to their health and wellbeing that they were asked about. It suggests that many do not access such groups or organised activities – or they are unaware that they may exist.

Social networks were important – the survey showed about 4 in 5 people who had used health and social care services found it easy to get help from a close family member (86%) and friends and neighbours (80%) if they needed it. Those most likely to need help, for example due to a disability or being on a waiting list for health services or a care needs assessment, found it comparatively harder to get help from a close family member, friends or neighbours. People with greater needs but weaker support networks might be helped through a systemic approach that involves the voluntary sector.

Better understanding of local populations might help address inequalities. For example, the survey showed people who find it difficult to get support from friends and family were slightly less positive about some aspects of services they get, such as whether their care and support needs have been met over the last 6 months. This group was also more likely to live in deprived areas (24% do, compared with 17% among those who find it easy to get help from a close family member, friend or neighbour) and be disabled (71% of them are, compared with 58% among people who find it easy to get help from a close family member). This suggests there is a risk of exacerbating health inequalities because these groups have slightly worse experiences of services and less developed social networks.

Many people are on hospital waiting lists, so there is a coordination role for local systems in making sure people feel supported and reassured while waiting for treatment. From our survey, we know that a significant proportion (37%) do not feel well supported while on a health waiting list, and for 40% of those on a health waiting list, their ability to carry out day-to-day activities is getting worse while waiting.