The negative impact of poorly managed long-term conditions is huge. Care of some 15 million people with long-term conditions consumes 70 per cent of the NHS budget in England, that is £77 billion annually, as well as £10.9 billion of the £15.5 billion spent on social care in England.
Without the appropriate action on long-term conditions, for example, you will continue to get unnecessary acute admissions. Patients end up at Accident and Emergency (A&E), before then being discharged unsafely back into the community, and then returning to A&E. It is a revolving door and unsustainable.
Yet, attention to a few distinct measures would make a considerable difference to the effectiveness of dealing with long-term conditions and, in doing so, to the overall effectiveness of the NHS.
There are four process issues, in particular, that are worth highlighting where action is possible and would make a significant difference: knowledge mobilisation; distributed leadership and accountability; collaborative strategy; and workforce development.
1 Mobilising knowledge
To begin with, the provision of first-class integrated care for long-term conditions is not possible without the mobilisation of knowledge across organisational and professional boundaries.
Unfortunately, many people seem to equate the concept of knowledge mobilisation with the implementation of an IT system that facilitates data sharing. And that is part of the problem.
Knowledge is different from data. Knowledge is embedded in practice. This is about ensuring that the different professionals in organisations understand each other’s perspective and are able to broker knowledge to each other in real time, in ways that make sense to the other party.
2 Making distributed leadership and accountability work
Work needs to be done on aligning performance. Typically, under the existing performance management systems different parts of the organisation point in different directions with respect to the performance indicators that they need to meet.
A classic example is targeted waiting times for A&E. If your job is likely to be at risk for not hitting a target you might, as a hospital manager, keep ambulances waiting outside A&E and not count them as coming into the hospital until you know that you can hit your target.
However, somebody in the ambulance trust will have their job linked to time targets for the ambulance service that is being provided. If the ambulances are stuck waiting outside at the hospital then there will not be enough ambulances to respond to calls.
Professionals will orientate towards their discrete professional indicators. A lack of performance indicators aligned to delivery of the overall service across domains, coupled with intense scrutiny and cost and quality pressures, creates incentives for organisations, or parts of an organisation, to act in dysfunctional ways that lead to inefficient and ineffective delivery of care.
It encourages gaming and fragmentation of the system. Instead we need broader, more sophisticated performance indicators that relate to overall service provision over the long term, rather than just the narrow and very direct performance indicators, such as waiting times at A&E.
In turn this will create the conditions to allow leadership to be distributed across organisations and professions, rather than having hospital medical leadership as the dominant force, for example. At the same time this must be supported by collective responsibility.
At present there tends to be a patchwork of discrete accountabilities, with each individual in the care provision chain feeling that their duty to the patient is discharged after their personal interaction with the patient.
Accountability is important, but we need to encourage a sense of collective responsibility for care of the patient over the longer term, focusing on long-term overall outcomes, particularly where care is discontinuous.
3 Collaborative strategies
In the current fragmented system individual service providers, whether in health, social care, education or another domain, develop their own strategies in isolation at an organisational level.
One reason that they do this, for example, is because marketisation and competition incentivises organisations to seek competitive advantage over other potential providers as they seek to sustain and develop the business.
However, although strategy needs to take place at an individual level, it also needs to take place in the context of the care ecosystem.
So while all these organisations have a local population to provide for, they need to engage in a strategy that is collaborative and that takes account of the other. There is some progress on this measure via Sustainability Transformation Plans. Nevertheless, the hospital is always a disproportionally powerful player.
Similarly, within and across organisations, managerial and professional conflict must be mediated in order to encourage those in managerial and professional roles to work collaboratively towards shared objectives.
For example, there is a need to bring policy and delivery together. Otherwise, policy is developed without any reference to pre-existing process and practice.
Thus, we need to ensure that policymakers, and not just executives but also middle level managers with clinical experience, engage with those who are delivering the care.
4 Workforce development
Delivering integrated care requires a multi-disciplinary delivery system. It needs a local level multi-disciplinary team that pulls in people from different organisations and professions to address patients with long-term needs.
In addition, there should be a focus on hybrid roles – professionals who move into managerial roles. This ensures that there is both the knowledge about what is required in clinical and social care, for example, but also that there is a good understanding about the resources needed for implementation in the particular local context.
The answer is not simply providing more doctors or nurses, either, something that is likely to take many years to filter through to improvements. But instead, finding ways to enable doctors, nurses, social workers and other key professionals that deal with long-term conditions, to become competent managers.
Here it is worth acknowledging that workforce development is perhaps one element of process reform that the Government has paid attention to. This can be seen in initiatives such as the NHS Leadership Academy.
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For further information, please visit https://www.wbs.ac.uk/ or Graeme Currie’s biopage https://www.wbs.ac.uk/about/person/graeme-currie
