Broadly, a whole systems approach is about identifying the various components of a system and assessing the nature of the links and relationships between each of them. Whilst it is not just about getting each party around a table to talk about their parts in the system and understand how they could work better together and impact on a wider population benefit or outcome, this is a key part of it.
With the increased drive towards integrated care within NHS planning over the past 10 years, the talk has turned to ‘whole population’ approaches; tackling the wider public health challenges through a broader consideration of roles and through ‘systems leadership’. Again, for this to work people have to understand the different parts of a system, their roles and how they could work together to achieve an agreed outcome. Sounds simple doesn’t it?
In practice, independent social care providers have found ongoing challenges in getting their voices heard at a strategic level, and many barriers to being part of the new systems that should be enabling this to happen. This is despite open agreement about the need for all parties to work together amidst the recognition that social care is in crisis. Engaging and influencing for an independent social care provider is actually not so simple.
Actions, not words
The NHS Five Year Forward View (NHS England, 2014), and Next steps on the NHS Five Year Forward View (NHS England, 2017) required NHS commissioners and providers to work together to develop sustainability and transformation partnerships (STPs) to improve services, taking a population-based approach to their geographical ‘footprints’. The word ‘provider’ is clear in here, as is the importance of community-based services for the plans and, critically, for the performance of the NHS. However, I will not be alone amongst social care leaders, whether from larger or smaller providers, in my frustration about the historical lack of proper engagement with the sector.
Central government, local government and NHS services across the country deliver multitudes of papers and plans talking about ‘consultation’ and ‘engagement’, as well as the ubiquitous ‘integration’, and yet the independent social care provider so often finds themselves excluded from key conversations. At best, our social care perspective is relayed through our local authority partners, whom we may feel themselves do not truly understand what we do, what our issues are and importantly, what we could do under different ways of working. This is a paternalistic approach better suited to the days when most social care delivered was directly from statutory services; not so much in the current system where independent care providers are an essential and integral part of our social and health care infrastructure.
Following on from the STPs, where strategic partnerships and collaboration were recognised as more advanced, there was further work to create integrated care systems (ICSs). These now see NHS commissioners, providers and local councils work collaboratively, taking collective responsibility for resources and population health. With no basis in law, ICSs are entirely dependent on a collaborative approach to leadership and a willingness on the part of the organisations involved to work together. What this can do is bring together the right people, with the right commitment and the drive to find solutions. This should give a better platform for more meaningful engagement with independent social care providers.
Making a breakthrough
Dorset is one such ICS area. Agincare has been the largest independent social care provider in Dorset for some years, providing a wide range of services across frontline homecare, live-in care, project work and care homes. The councils and the clinical commissioning groups (CCGs) spend significant sums on social care provided through our services and we have long-standing contractual relationships with them requiring ongoing interaction, review and monitoring.
On our journey and growth into other areas across the country we have often sought to share knowledge or experience from other areas or to offer a more ‘whole system’ observation about our own and others’ working, investment into the area and our own active links into national sector issues. However, even though the ICSs, (like the STPs, like the PCTs, like… ok you get it), should see NHS commissioners, local councils and providers working together to take collective responsibility for resources and population health, in reality this has usually meant the NHS and the councils still speaking on behalf of their independent sector providers.
Such ongoing challenges with whole system approaches and ‘real’ inclusion of all parties are of course understandable. As Professor Chris Ham, The King’s Fund (NHS Providers, 2018), said ‘it is important to recognise that ICSs have no basis in law and are entirely dependent on the willingness of the organisations involved to work together. NHS Trusts and CCGs have their own statutory duties and members of their boards may need reassurance that these duties are not being compromised by ICSs…Different accountabilities in the NHS and local government may also cause tension.’
In Dorset, whilst we had two long-standing and professionally-managed provider associations, neither provided a high enough representative number of providers, either across the county or across service provision; this made it more difficult to include them in wider strategic discussions. After some impetus from an interim director and many months of negotiations (and the use of external consultants via the Care Provider Alliance), we have been able to successfully work together to form a plan for a recognised strategic provider group, which will be able to put forward independent sector representatives for a range of groups, including the ICS.
Hindsight is a wonderful thing, so some key points I would recommend based on experience include:
- Know what is going on nationally and locally; think about how your services link in and can support current programmes or un-met needs.
- Think big and think realistically; providers won’t be asked round the table for strategic debate if they simply bring a micro view about their own provider issues, or another £0.50 on an hourly rate. This is bigger, longer-term thinking and, for credibility, you need to be prepared to speak on behalf of the sector, not just your own position.
- Be aware of your local networks and leaders. There will be a range of approaches, from people working in their own bubble, blissfully unaware or uninterested in roles and functions outside of this, right through to passionate individuals who are just as eager as you are to link in and innovate.
- Get used to the jargon and understand each other’s language; the dreaded acronyms, the people, the places, the plans.
- Engage with your provider associations, especially the national ones who can help advise and support you on effective approaches and methods of engagement.
- Smaller providers may find it useful to link through their own local provider association, to stay informed and updated via nominated representatives.
- Write to your local groups. Let them know about social care issues and the vital services we provide. But don’t whinge!
- Be prepared to put in the work if you want to be directly involved. No matter how well-intentioned all parties are, you must be prepared to put in the time and effort, sometimes even when it feels like there is no obvious benefit.
- See all interaction as a potential for learning. I firmly believe that a large obstacle in working better together is often a simple lack of awareness about others’ roles, services and the relationships between them. Offer to attend meetings and present on social care. And keep an open mind about the stresses and strains for other colleagues and link in how your social care provision could alleviate some of them.
Small steps forward
There will always be issues with the capacity of people working across health and social care, thanks to changing roles and high turnover sometimes leading to a short-term working approach. There are obvious differences and tensions in relation to funding streams and priorities. The NHS has particularly bureaucratic constraints that can at times clash with social care decision-making and frustrate independent sector providers. We also know that the social care ‘market’ is huge and dispersed – that’s partly why it’s so important that we are in the discussion – but that brings major issues for direct public services.
The poor media coverage of the social care sector does not help foster trust and confidence. There are multiple independent providers in any given area, too many to invite all of them and many not engaged with their sector through formal measures of public contracts or membership of professional associations. Many micro-providers are busy delivering care as well as managing their businesses and simply do not often have the time to commit to engagement and influencing.
Despite having been engaged in sector debates at a national level for many years, often through our hard-working and effective United Kingdom Homecare Association (UKHCA), the journey into any strategic debates in our local areas has been tough. In Dorset, it feels like we have made a breakthrough, but having attended these meetings, I still feel there is much work to do. We can only hope that with an increasing number of integrated services and with more interaction through strategic groups, the independent sector will become both more confident in its approach and more accepted by the public services it forms such a critical part of.
What are your experiences of these conversations? What hurdles have you encountered and how have you overcome them? Share your advice in the comments below.