Integrated Care Systems – navigating ICS organisational maturity

April 1st 2022 will see regional health and care systems being given statutory body status in England. Each Integrated Care System (ICS) will become responsible for strategic healthcare planning and allocation decisions, and accountable for spending and performance within its boundaries.

With such big changes ahead, developing ICS organisational maturity will be key to success. The new ICS Design Framework, ‘What Good Looks Like’ (WGLL), is aimed at supporting this development, focussing on 7 key measures:

• Well led
• Ensure smart foundations
• Safe practice
• Support people
• Empower citizens
• Improve care
• Healthy populations

ICSs will need to develop transformation strategies that pull together these 7 areas through delivering organisational change, and connecting and digitising care to remove silos and improve both care pathways and citizen experience.

How can ICSs navigate the complex and, potentially, bumpy transformational journey?

It is widely recognised that the components of successful transformation are People and Process with Technology utilised as a key enabler, though not as a fixer of problems. Good governance is essential, as well as robust inter-organisational processes, and empowered citizens and staff. Winning the hearts and minds of all stakeholders through genuine inclusive engagement and open communication is fundamental to success.

There will always be the challenge of prioritisation and finding the balance between mandatory initiatives, citizen and staff expectations, resources (human and financial), and finding ways to improve patient care and reduce costs and waste. Real world examples and recommendations from peers at other ICSs can help with prioritisation and with understanding the associated capacity and capability requirements, creating a stable foundation for developing organisational maturity and for the supporting change management and digital transformation that will drive real-term ROIs and benefit realisation.

Assessing and improving organisational maturity

A comprehensive approach is needed that considers the key areas of clinical and social care, governance, and technology.

As the UK’s leading HIMSS Digital Health Technology partner, Ideal has worked with 14 ICSs in the last 18months to conduct maturity assessments from the perspective of continuity of care across each ICS, with domains and focus areas that are aligned with the ICS Design and WGLL Frameworks.

We have engaged with over 120 organisations to develop a comprehensive view of ICS organisational maturity, including secondary and primary care, community and mental health, social care, ambulance services, private and third sector providers and, in some areas, housing organisations; all too often forgotten as important influencers of public health.

Focus area 1: Clinical and Social Care

1. The Citizen/Patient Experience

A prominent and important focus area, this should not be considered as simply a benefit of better joined up care. Engagement and co-design, utilising citizen councils and workgroups, should become the norm, since it is a major driver of transformation. Incorporating user experience (UX) design also demonstrates an organisational culture that is genuinely citizen-centric.

2. Shared Care Record (ShCR), Health Information Exchange (HIE) and Personalised Health Records (PHR)

Interoperability and data sharing needs to be meaningful, ensuring that the right data is available on demand, wherever and whenever it is required, but in a way that can be interpreted easily by the person viewing it. A one size fits all approach will not work and each will need its own development roadmap.

3. Population Health Management (PHM)

ICS-level Data and Analytics strategies should be in place before tackling PHM. This should not simply be a top-down analytics approach focusing on risk stratification and predictive analytics. Robust data quality (which is an ongoing requirement) should be considered when connecting data warehouses, EPRs and other repositories into ‘data lakes’. Without quality data, the issue of ‘rubbish in – rubbish out’ becomes very real.

4. Care Co-ordination and Flow

The most common complaint from health and care providers, and from citizens, is the lack of co-ordination of care. Large variations in discharge/transfer procedures, inability to see patient details, handover failures, and the loss of patient data between organisations all lead to increased clinical risk, significant waste of time and resources, and frustrated staff and citizens.

Focus area 2: Governance

1. Organisation

Having a Digital Transformation Board which has good senior-level attendance and mandatory clinical and care representation is crucial. However, this should have direct links to the ICS Board, clinical and care groups, and patient/citizen councils. Each of these need clear terms of reference and communication routes to avoid creation of working silos. Communication to staff and citizens will also help manage expectations around timescales and changes, mitigating perceived lack of pace and progress.

2. Strategic Alignment

Acting as one can be an issue, but commonality of purpose with aligned ICS and partner strategies is essential. Clear, planned and regular communication is again essential.

3. Information Governance

Data sharing has improved, but is by no means standardised and the time it has taken to agree data-sharing agreements has caused strain and delayed progress. “Borrow” them from where they have been successfully applied elsewhere.

4. Workforce Enablement and Learning

This is what will define the successful adoption of SHCRs, or doom them to being “just another system”. Availability, format and setting for learning all have to be considered. As with any other enterprise-level system (EPR, EPMA, etc.), reliance on e-learning alone will not be sufficient. Clinical and care staff will have different needs depending on how a SHCR is integrated into their own system (or as a separate system), so optimising learning management is essential.

Focus area 3: Technology

1. Infrastructure and System Capabilities

Most of the infrastructure in place for health and care has been developed from a history of silos. Specific attention to infrastructure at a regional level needs to be considered, including use of cloud, machine learning and automation alongside network design and accessibility. Speed to access records and data, as when required regardless of location, are important considerations, as are resilience, security and sustainability as mandatory requirements.

2. Person Enabled Health and Care

Technology-enabled care features in many digital strategies and can improve a citizen’s compliance and engagement with their own care, reducing urgent interventions. Social care has much to offer in developing these solutions, as they have been utilising telecare and remote monitoring and home care solutions for many years. These models can be leveraged for broader integration of devices and apps. Many ICS now include digital inclusion as a priority in their transformation strategies to improve accessibility and citizen choice.

Opportunities to Improve Maturity

1. Vertical integration

Some provider organisations have poor digital maturity with limited capability to merge their own internal IT systems, let alone share across care boundaries. This will make it more complex to connect to the ShCR and risks dropped data and incomplete information arriving with clinicians and care workers.

2. Culture

There are still significant numbers of paper-based processes despite the prevalence of digital solutions.  This suggests more thought needs to be given to the process and people change aspects of digitalisation when introducing new solutions to truly transform how staff work. Covid-tired staff and ‘change fatigue’ are real issues.

3. Data strategy

Having a clear shared data strategy, noting who owns the data, remains a gap for many ICSs.  This should be developed within the Digital and Data Strategy to ensure clinicians and care workers know what they are viewing and where from. Clarity around data origin will also ensure datasets can be combined and analysed prompting action earlier and smarter patient interventions, or informing the redesign of services.

4. Scale of change

There are frequently too many projects needing rationalisation and prioritisation.  This appears to be most pertinent for smaller organisations which have to address each project with far fewer staff resource and money. “Parity of voice” for smaller organisations within ICS would support more realistic project plans. Levelling up funding should be actively pursued.

5. Maximise resources

Given shortages of digital and data analysis staff, there is opportunity to build shared service across ICSs. This would maximise skills availability, providing better career pathways for staff and sharing teams for major projects and programmes. Resources will be an issue moving forward and “pooled” resources and expertise create SMEs within individual organisations and longer term sustainable support for the further development of systems, managing change and engendering a culture of innovation.

6. Digital capabilities learning and digital literacy

Many staff recognise the need to up-skill digitally. This is also required in the wider population, building upon the advances during Covid.  Learning from other areas and regions requires more systematic approaches to avoid reinventing the wheel. Consider staff sharing, or seeking a mentor ICS or learning partner would be a quick way of addressing this, undertaking organisational raids for best practice.

7. Scaling up the Shared Care Record

MVS 1.0 is merely a first step and in many cases there is a gap between meeting the criteria and having a meaningful SHCR that delivers benefits to health and care staff. Additional guidance is due by end 2021 on wider implementation of shared care recors in 2023/2024. Incorporating staff experience (UX) must be utilised to create an agile/iterative development roadmap to ensure frustrations do not derail progress. Bi-directional communication and engagement is required.

Mapping the Route: 7 Key Recommendations

1. Assess maturity against WGLL criteria and focus resources into levelling up; an ICS is only as mature as its least mature organisation.

2. Agree top 10 shared actions within the ICS Strategy with lower priority actions phased into a clear roadmap gradually, appreciating and sequencing the individual partner activities that must happen first (or concurrently) to achieve the overall ICS ambitions. Don’t try to boil the ocean!

3. Define a Data Strategy with clear data origins, develop bi-directional data flows and phase 2 of the ShCR. Develop an HIE approach within the data strategy to ensure EPRs, the ShCR and PHRs align to provide clear patient data flow between systems and devices.

4. Address ‘digital literacy’ and inclusion across the partner organisations and the wider population to help support current and future digitally-enabled health and care solutions.

5. Adopt a patient journey approach to designing digital solutions across boundaries, assessing pathways and clinical/non-clinical journeys to help inform future requirements and improve handovers, continuity of care, and data flows to all involved.

6. Consider wider super-regional requirements for a regional shared care record, given out-of-area patient flows and Ambulance Services operational realities, learning from existing LCHR/regional care records.

7. Engage citizens/patients directly in the co-design and development of digital services appreciating the particular requirements arising within certain groups to support digital inclusion.