The Achilles heel of Integrated care – ‘The space between’


Guest Blog Healthcare - Michael Shaw

Senior Systems Transformation Strategy Consultant

The NHS in England is a service striving to meet an ever growing, complex age and lifestyle related activity dependant population, a service built upon the hospital model, a model which hasn’t adapted to this changing demand. It is currently halfway through the most austere decade in its history, where funding has not kept pace with demand. The answer, according to the Department of Health and NHS England is the 5-year Forward View.

A plan that asks the NHS to look locally for answers; closer clinical and service integration between hospitals, community services and general practices, health and social care, and mental health. Health and social care budgets pooled and organisations expected to work together in place-based systems of care; to identify, design and deliver new models of care, using the resources currently available and to break down barriers between services and organisations for the benefit of the local population.  

It is those barriers and the space they create between organisations that could well be the Achilles heel in the delivery of such plans.

The current conversation quite rightly is about the money, but the journey has started; the money will be found (maybe not all of it), but it will be found. The problem is that money has very little to do with closing that space. The 5 years Forward View and the STP’s/ACO’s created to realise that plan are built on the foundations of collaboration between separate and in some instances opposing parts of the same system. Independent sovereign organisations, which like any entities within a system will do all they can to survive.

In listening to healthcare colleagues and reading the media you get a sense that collaboration is a given, it will just happen. Maybe that optimism stems from the public service ethos; that this is for the greater good. However, as a pragmatist, a system thinker, somebody who has worked in the public sector for the last 12 years; bringing together different parts of the same system (NHS) or different parts of different systems (NHS & Local authority) is I believe; complex, challenging and unless approached through the science of change; fraught will difficulty. I recently heard disturbing mutterings about ‘forcing’ organisations to collaborate (a bit of an oxymoron if ever I heard one)!

To achieve and sustain an operating model of integration between sovereign organisations, strong relationships; leader to leader, clinician to clinician and clinician to social worker is fundamental. A culture of collaboration, teamwork and transparency needs to be nurtured to overcome the inherent organisational and professional boundaries. Bottom up change as a result of pathway re-design, combined Capacity Management Centres and multi organisational frameworks for operating will begin to expose the differences between the top down design of each organisation and the bottom needs of the system. In working together, system leaders can co-produce and put into practice a series of overarching design principles, building blocks (both physical and more importantly psychological) which will begin to close the space between the organisations, while retaining their sovereignty

System Operating Principals

1.    Clarity (Purpose & Vision)

A shared purpose and vision of the combined system and a description of the outcome(s) required of the system and how it will add value to the patient.

2.    Strategy

A strategy that combines and aligns the objectives of all the partners/services/providers involved in delivering care to the population, this customer focused strategy should have short, medium and long-term objectives. The capacity and capability to define and align the strategy would be through a central system shared service planning function.

3.    Connectivity

 A supporting infrastructure to connect and cultivate relationships, to facilitate partnership working at all levels between all the organisations across the system.

 4.    Defined Way

A defined “way” of working that states the values of the collective partners; an alignment of values and behaviours frameworks so staff know what is expected of them in their day to day roles. This psychological co-created statement will influence and require alignment to the physical human resource systems across all system. (E.g. job descriptions, appraisal frameworks, the creation of HR shared services, etc.).

5.    Route Map

A tactical route map of delivery which phases the system component changes. System leadership, change capability, capacity and infrastructure needed to realise the plan.

6.    Leadership

  • A model of distributed leadership which permeates the whole system. For the system leaders, this involves developing and nurturing a style of leadership where;
  • All members of the system have a greater understanding of and continuous input into the development of the microsystems, mesosystems and the collective macro systems; strategy, values and goals.
  • A coaching and a facilitation model of behaviour to counter balance a pace setting style.
  • Performance facilitation is key; allowing individuals to operate within the boundaries of their defined framework or operating.  

7.    Alignment

An alignment of how the whole system approaches transformation and change. In-house disparate improvement capability and capacity needs to be brought together in a central shared service function. A right sized centre of expertise; resourced with System Engineers to support front line teams to design and redesign pathways, and microsystems.

Investing in the capability of all leaders and front-line staff in practical problem solving and quality improvement will mean that they are able and willing to identify the root cause of problems and with the support of the System Engineer will solve those problems as they arise.

Where differential organisation design models operate within the same system and especially between different systems; the flow of understanding and transference across organisational boundaries is often restricted and collaborative and partnership working can be difficult to achieve. A physical and more importantly psychological infrastructure, a system thinking and improvement science approach is needed, an approach that connects and cultivate strong relationships and facilitates collaborative working.

Click here to know more about system design and how to connect, integrate & operationalise your local system.

A living system: Health and care


What would a Health & Care system say if it could talk?

Hello my name is H.A.C and I am a system. 

I am complex in nature, difficult to understand and challenging to change. I am made from multiple inter-connected horizontal parts but expected to deliver services along vertical cross cutting pathways. My interconnected parts don’t always get on and some never talk at all, but each and every one of them will do all they can to survive. 

If you do not know me and then try to change a part of me, another part of me may no longer work as it should and unintended consequences can occur, which are not my fault. 

To know me is to understand the whole of me. 

To understand the whole of me is to know where my inter-connected parts are aligned and where there is a space between. They tell me that in order to eat an elephant, it is necessary to eat it a piece at a time. So to understand me, is to de-construct me, a piece at a time, pathway by pathway/patient user cohort by patient user cohort, microsystem by microsystem, organisation by organisation. To understand me is to know where I meet and where I fail the needs of those whom I serve, where I am productive and safe and where I am not and where I get it right first time and where I fail time and time again. 

To understand me, gives you the power to change me. 

Design my change properly and I give you the power to control me. Design me poorly and you risk consequences occurring which you never imagined. Consequences which are not my fault. 

To change me; is to change physically how I operate but more importantly how I think and behave. 

To keep that control, you must maintain me, nurture me and continually improve me. To leave my individual components to go their own way, out of context of the whole of me, risks infecting me with ambiguity, inconsistency and variation. Ambiguity, inconsistency and variation are the fuel for failure demand, failure demand at best is re-work, at worst a clinical incident. 

You will have lost control of me. 

To know me is to understand me, to understand me enables to you to change me, to change me gives you the power to control me. 

I am not alone; I am one of 44.

This is an extract from ‘Health & Care; How to connect, integrate and operationalise your local system. 

Download the free white paper to understand how the NHS can tackle this challenge using systems thinking and the Toyota way. 

Building GP Capacity and Resilience: The Productive GP Programme from NHS England



Guest blog, Healthcare - Ross Maynard

Productive General Practice Coach


As one of the coaches on the Productive GP Programme run by NHS England, I work with GP practices to improve their processes, strengthen their resilience and expand their capacity in a number of ways. One of these is to look at frequently attending patients.

The process is fairly simple:

1) Identify those patients who consume the most appointments in the practice

2) Review their patient records to determine if other clinical or support services could be used to ease pressure on appointments and improve patient care.

The systems that GP practices run make it easy to identify those patients that attend frequently. Doctors and practice nurses then get together to review patient information to see if other approaches might help to reduce the demands that these patients place on the practice to release space for other patients. These alternative pathways might include interventions from mental health specialists and other clinical professionals; alternative therapies; as well as voluntary and community groups and services.

In my experience, many of the patients who consume the most GP appointments have mental health or addiction issues. The extent to which other services can help reduce dependency on the GP practice will depend on the provision in the local area. Nevertheless it may be possible to reduce the burden on the GPs alone by taking a more proactive approach to scheduling appointments – sharing appointments between a nurse and GP for example – and being clearer about how often the patient needs to be seen.

Some practices are lucky enough to have the space to arrange clinics specifically for mental health issues; for counselling; and even for advisers to come in to try and address the social issues that lie behind stress and anxiety.

Let me give some examples:

In many surgeries, it is the time of the practice nurses that is under most pressure. In one small practice, with only 2 part-time nurses, training Health Care Assistants to change dressings freed up approximately 150 nurse appointments per year.

In another small practice, frequently attending patients were not much of a problem – there were only 22 patients who had had more than 10 GP appointments each in the past year. However, even there alternative interventions for six of the patients helped reduce the pressure, and gave the patients a more comprehensive care plan.

By contrast, a large urban practice had nearly 800 patients who had 20 or more appointments (GP and nurse) each in the previous year. This equated to 7,900 consulting hours. Nearly 300 of those patients had over 30 appointments in the previous year (nearly 2,000 consulting hours). Here the ongoing work to reduce the impact on resources of patients who, medically, don’t need to be seen so frequently has the potential to release considerable capacity, so that patients trying to get an appointment can be seen more quickly.

With another mid-sized suburban practice, only 15 patients had had 30 or more appointments in the previous year. A review by the GPs identified that 7 of them could be referred to recently enhanced mental health provision in the area.

Of course many patients who attend surgery frequently do need to be there. But taking the time to review records, particularly in a multi-disciplinary meeting, can help identify new approaches and ease some of the pressures. Even a reduction of 10% or 15% in the number of appointments generated by frequent attenders can make an important difference.

And it is not all just about frequently attending patients. “Zero attenders” also represent a golden opportunity for practices to focus on preventative work. Among the patients on the list who have not requested an appointment at all in the last year (the “zero attenders”) many will have conditions where some proactive preventative work will reduce costs for the health service should those conditions worsen. Such groups include those with diabetes, asthma, hypertension, and so on.

For example, one small practice identified 150 patients in the eligible group who had not attended a smear test in the last five years. These patients had had all the usual reminder letters but, rather than let it lie at that, the practice took a proactive approach to telephoning the patients to explain the importance of the test. A reasonable proportion of that group (about 20% at the time of writing) subsequently attended for the test.

Another practice targeted patients in the eligible group who had not undertaken the available bowel cancer screening, as well as those missing their smear tests.

Another small practice focused on high blood pressure, asthma and patients with a BMI over 35+ and, with a coordinated approach, successfully got many of them to attend for health advice and a review of their prescription drugs.

This is the sort of work that GP practices should be doing. It is good for patients and it saves the NHS money in the longer term. Often, however, practices do not get to do as much of this work as they would like because they are dealing with other workload pressures. The Productive GP Programme can help focus on some of these issues to improve processes and develop better plans. Of course this requires a time investment to review processes and activities, but the benefits far outweigh this input.

Addressing the medical needs of patients who request and attend many appointments enables a practice to improve the care it provides and, at the same time, free some capacity to undertake more preventative work with patients who would rather not attend their GP clinic. The data is relatively easy to extract. Time is then needed to review records and develop appropriate plans. The time spent on this valuable work will reap benefits for the practice and help improve the care it provides to its whole community.

Those working in GP practices might like to find out more from their CCG, or visit 

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