The four things that will make or break the integration agenda

NHS collaboration has always been an abstract concept. In its most simple form it represents different, and at times distant, organisations working together. The political push for these groups to work closer has always been complex. Ultimately, a system that has spent thirty years hardwiring in competition is always going to struggle to drive collaboration.

This is why the Health and Care Bill is seeking to unpick many of those structures and embed a new collaborative healthcare system. Under a ‘Duty to Collaborate’, NHS and local Government are now being pushed to worked together, with NHS providers duty bound to have regard to the systems financial objectives.

However, what does ‘Duty to Collaborate’ actually mean? I want to share with you the four things required to make this a success.


  1. Clinical leadership

Examples of successful collaboration usually rely on strong leadership. The next few months will be a complicated time for the NHS, with groups of providers coming together into Collaboratives while Integrated Care Systems move forward to full implementation. Service redesign and pathway integration are perceived as key drivers for improvements. In order to succeed, clinicians have to be part of the process, just as leadership will be essential for cross-domain joint working. This is easier said than done, and effective leadership will be critical to deliver results.

  1. Appropriate incentivisation

A key element of the new system is the ability for local NHS organisations to come together, set their priorities and fund them appropriately. Bringing together payers and providers under the auspices of an ICS should support this process. It is critical, however, that the new system is able to prioritise care across all pathways.

Why is this important? Redesigning services and pathways to promote integration and improve outcomes for patients often suggest a shift in the burden experienced by specific services. These shifts can then have a knock-on effect on service-specific budgets and resources. As a result, the improvements and benefits stemmed from integration may not be proportionally expressed across all services. Under these circumstances, some organisations may be disincentivised to implement change, and may pose resistance to an integration agenda.

The issue of incentivisation has been explored in the past, and progressive policies can help manage risk, and move people to act differently. Gain-share agreements serve as a good example of joined-up thinking between payers and providers. Instruments of this kind aim to balance not just the burden, but also the benefits, that may come from changing practice across services and budgets. Through these principles, comprehensive incentivisation can be achieved, accelerating the integration agenda.

  1. Funding transformation

Changing the way services are delivered in the NHS requires substantial resource. The development of new pathways and services require appropriate financial support ahead of, and during, their implementation. At the same time legacy pathways and services must remain operational throughout the transition process to avoid disruptions in care. In the context of a substantial backlog and workforce barriers, it is not hard to understand why service transformation is perceived as a challenge. For integration to deliver results, system leaders must account for these realities and facilitate comprehensive support for providers to develop and implement transformation.

  1. Unintended consequences

Finally, efforts must be made to mitigate the risk of unintended outcomes that may stem from the integration agenda. In the short term, the risk is that specific regions may be better equipped to deliver the integration agenda than others, and with it improve health outcomes for patients. These improvements, while desired, may naturally increase the gap between good and poor performers, exacerbating regional variation.

Careful attention must be paid to the regional progress made. The NHS should be ready to increase resource and leadership support if progress is lacking and help ensure no regions are left behind.

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