Integrated neighbourhood teams: lessons from a decade of integration

One of the major themes in health care policy over the last 15 years has been the development of integrated care and a more place-based approach to how services are organised. Two years ago, the Fuller Stocktake proposed the development of integrated neighbourhood teams, and their implementation is underway across the country. These teams are intended to help by focusing on:

• streamlining access to care and advice to meet the needs of infrequent users of health care services
• providing more proactive, personalised and multi-disciplinary care for people with more complex needs
• helping people to stay well for longer, through a joined-up approach to
  prevention.

These are goals that the NHS can get behind, but previous experience shows it is difficult. Indeed, implementation is proceeding somewhat more slowly than might have been hoped. An understanding of the history of attempts at integration shows why this might be the case, and also illustrates some other important lessons. As people who have carried out research in this area and have worked for many years with teams attempting to integrate, we have distilled some simple, yet important, lessons from the literature and our own experience that are just as relevant to the next stage of this process. 

1. Be clear about definitions

Integration as a term is often used rather vaguely to describe a range of different types of change in organisations, systems, processes and culture. The literature reflects this and has a very large number of different definitions of integration. The picture has become more confused as there is an overlap between the ideas and techniques of population health management and those of integrated care.

Clarity from the outset about what is meant by integration, and what it is hoped will be achieved, would be helpful. Defining this in terms of practical ideas such as reduced fragmentation or improved coordination can provide a more straightforward and compelling narrative.

There may also be a need to be clear about what constitutes a neighbourhood, as this is not always straightforward. For example, local government, community trusts, primary care networks (PCNs) and the integrated care board can have different approaches to this. There is a risk that the NHS’s desire for neatness and for systems to be easier to manage for large organisations cuts across the perceptions of local staff and populations. Equally, the configuration of PCNs can also cut across boundaries recognised as neighbourhoods by others.

A third definitional issue is what constitutes an effective neighbourhood team, who is a member of these, how do they relate to more specialist services, and whether there are upper and lower limits on team size that need to be considered. The temptation to include everyone may mean that they will lack coherence.

As Michael West has pointed out, there is a risk of creating pseudo-teams of people who think they are in a team but where few team-like characteristics are present. This is worse than no teamwork at all. As a result, there is interest in creating ‘team of teams’ approaches to enable teams to work on a human scale while being able to scale up where necessary or where other expertise is required.

In some areas, a question is being raised about the centrality of general practice in the integrated neighbourhood team (INTs). One common factor in some of the less successful attempts at integration has been a failure to have the core primary care team in a central role. However, the challenge of engaging general practitioners should not be underestimated. Integrated working has been seen by GPs as a source of additional activities rather than as a way of working more effectively.

It is also true that integration is not cost free in terms of time. For some functions providing services that are more specialised or used less frequently, it makes more sense to involve them on a transactional or as-needed basis than to closely integrate them into the service. In fact, as Walter Leutz points out in a key article on integration, overdoing integration can simply recreate barriers and fragmentation within the organisation. You can’t integrate all of the services for all of the people, all of the time.

2. Beware of poorly formulated objectives

There are lessons from integration experience for INTs in the way that objectives are set. For many of the integrated care initiatives, these have often been framed in terms of:

• reduced emergency admissions for ambulatory care sensitive conditions and long-term conditions
• reductions in length of stay
• reductions in emergency department use
• cost reductions flowing from these and from improved coordination and care planning.

Much of the evaluation literature suggests that integrated care is unlikely to deliver significant changes to hospital activity and costs in the short term. In fact, more effective integrated teams might even identify more patients who need specialist input. One study looking over a much longer timeframe suggested that after six years of integration, the impact on hospital care began to become apparent. So perhaps the lesson in this regard is that patience is required. 

There is also a question about whether framing the purpose of this work as being primarily about helping out hospitals is a narrow approach to an enterprise that needs to engage staff in new ways of working. A lesson to draw from this is that INTs should try to set objectives in broader terms about population health, inequalities, and crucially patient and staff experience.

The existence of contracting models and staff management approaches based on caseloads and activity is a particular hazard here. A focus on patients or the needs of the population is needed, and how to deliver the care they need rather than following the dictates of an activity-based contract. Doing the right thing, solving the patient’s problem, responding to a request for assistance from another part of the system, intervening opportunistically and other important aspects of professional care in an integrated system are hard to incorporate into a contract and will need some thought. Many current approaches to both community contracting and the management of many community staff are clearly not fit for purpose.

3. The patient focus can get lost

The motivation for clinical teams to integrate is largely founded on the desire to provide better quality care and a better experience for patients. However, perhaps surprisingly, this isn’t always how patients may perceive integrated services. For example, the evaluation of integrated care pilots in 2012 found that, in some key aspects, patient satisfaction fell despite the best efforts of the service providers. 

It is possible that patients particularly value aspects of care that are harder to maintain in an integrated system. For example, continuity of care with a particular clinician may be lower if additional (clinically effective) roles are newly created.

At the same time as efforts to create integrated teams, there has been an increasing trend to split work into tasks and allow the deployment of less experienced and qualified staff. At a Nuffield Trust seminar, Professor Alison Leary pointed out that this can undermine continuity of care and lead to the loss of a view of the whole patient.

In the care of more complex patients where understanding their personal narrative and context are key, this will reduce the effectiveness of care. Adopting the Buurtzorg approach of using higher grade staff who may not always be working ‘at the top of their licence’, but who can provide continuity, may be a more effective way of improving patient experience, and is less likely to cause fragmentation than distributing tasks between different staff. It could also reduce coordination costs and the burden of supervision on senior staff imposed by a mix of different types of staff.

At the very least, would-be integrators should anticipate that changing long-tested ways of working might cause some anxiety and need to be explained very clearly. Of course, involving patients in the design (and prioritisation) of services to be integrated is always recommended.

4. It can be easy to overemphasise the role of structures, governance and payment mechanisms

The blame for current ‘disintegrated’ services is often placed at the door of unhelpful systems of governance and payment systems. And it is unarguable that various policies such as Payment by Results and institutionally based performance management and regulation have played an important part in obstructing integrated working.

However, it may also be a mistake to overly focus on structures and incentives in the first instance. Changing professional boundaries and cultural norms will prove challenging enough. As will simply carving out enough time in the stressful working week for clinical and other team members to design and implement change, and to develop some of the new team relationships that also seem to be an important part of the process.

Moreover, integration itself can prove complex and onerous, especially if too sophisticated an approach is taken – diverting energy and time to governance and organisational design rather than the business of service improvement.  

However, INTs need to have effective decision-making machinery, and the complex nature of the current primary care architecture can be an obstacle to this. Making this work with as little structural reorganisation as possible needs to be the goal.

A more effective approach to integration might be that of ‘purposeful incrementalism’ – initially prioritising and tackling more micro-problems that have been identified by clinicians as getting in the way, albeit selecting solutions that broadly drive change in a coherent direction. Over time this can generate wider system change, but on the back of practical achievements rather than in advance of them.

5. The barriers to integrated care are well-known but seem to be stubborn

Many evaluations of integration initiatives identify a common set of barriers. These are relevant to INTs, and they include:

• sharing information across teams and organisations
• developing new roles and employment routes
• a lack of time to lead and engage with change (especially among GPs)
• a lack of additional resources to support development (including ‘double running’ during implementation).

What is perhaps surprising is that, despite clear identification, these issues continue to crop up. Solutions to issues such as information governance are also reinvented when they were already available and, while it is true that many elements of the development of integrated services are context dependent and best developed locally, this is not a universal rule.   

Maintaining GP engagement in integration activity is a vital ingredient of the recipe. Given the stresses facing this sector currently (and their degree of autonomy, allowing them effectively to opt out of discretionary activities), it is going to be very important to ensure that the changes have a positive impact on their work experience and reduce some of the problems they often experience.

The somewhat patchy history of partnership arrangements with local government and other agencies also demonstrate how difficult these can be to develop, and the extent to which they are vulnerable to changes in national policy.

6. It takes time

An unfortunate truth is that integration takes time. This isn’t just about the process of designing and delivering complex service change, but about developing the relationships that are key to successful implementation. These relationships can’t be forced. Many integration pilots and forerunners have had the benefit of pre-existing relationships that have helped (and even they have found it hard to develop a new consensus).

If you are not fortunate enough to have good cross-sectoral relations in place, you simply have to invest time building these. Similarly, pretending that there are not status and power gradients is a mistake.

To make matters worse, there is often the greatest focus on integration when health and care systems are under strain and looking for a ‘solution’. These are not the ideal conditions in which to address difficult and deep-seated issues. This has been dubbed the ‘integration paradox’. A lack of resources, including those to support an integrated care model, has been the stimulus for the introduction of that care model.

7. Policy stability is important if integration is to thrive

One feature of the integration debate over the last decade has been the rapid change in national policy. Many initiatives have come and gone (integrated care pilots, integrated care pioneers, new care model vanguards to name but a few). This has not helped front-line teams who need time, space and continuity, but instead have had to contend with an unhelpful turbulence.

More optimistically, the development of integrated care partnerships and boards and, beneath them, multi-agency partnerships around ‘places’, does at least provide a supportive context for the development of greater integration. However, for integration to thrive, system leaders will need the courage to devolve power to front-line teams, if truly creative solutions are to emerge.

Conclusions

The good news is that integrated care is firmly on national and local agendas, and that there is a wealth of learning from earlier integration efforts if policy-makers and implementers choose to explore it. The creation of universal integrated health and care partnership structures provide perhaps the most helpful context that would-be integrators have faced to date.

But there is a risk of course that a national push for INTs will force local standardised solutions that fail to take into account local history, geography and relationships. If INTs are to develop as real teams, they will need freedom to think for themselves and agency to act. This may feel challenging for integrated care system leaders, and could be particularly challenging for community providers who may need to change how staff are organised as well as other aspects of their operating model. They may also have to cede power and autonomy as part of this, which may be uncomfortable.

A key area where more attention might also be needed is in understanding how the nature of the work of staff in integrated teams will change. This is particularly the case for GPs and their staff, but also hospital staff where concepts of integrated care have probably been less discussed over the last decade.

There has been a persistent tendency for integrated care to be seen as a magic bullet rather than part of a set of interconnected approaches which include the development of primary care, information systems to support population health, investment in staffing and other elements of system redesign, including organisational development and giving staff time to think. Expectations have often been set too high and the opportunities for solid, incremental change have been underestimated. While incremental improvement may not lead to transformational change and innovation, it will lay the foundations in terms of relationships, systems and processes and in tackling some of the barriers to change. More measured approaches and patience may be needed. 

*Nigel Edwards is a Senior Associate of the Nuffield Trust, having been the organisation’s Chief Executive between 2014 and 2023. Dr Richard Lewis is an independent strategy consultant and a Visiting Senior Fellow at the Nuffield Trust.

References

Clarke GM, Pariza P, Wolters A (2020), The long-term impacts of new care models on hospital use: an evaluation of the Integrated Care Transformation Programme in Mid-Nottinghamshire

Erens B, Wistow G, Mounier-Jack S, Douglas N, Jones L, Manacorda T, Mays N (2016), Early evaluation of the Integrated Care and Support Pioneers Programme: Final Report

Lewis RQ, Checkland K, Durand MA, Ling T, Mays N, Roland M, Smith JA (2021), Integrated care in England – what can we learn from a decade of national pilot programmes?

Roland M, Lewis R, Steventon A, Abel G, Adams J, Bardsley M, Brereton L, Chitnis X, Conklin A, Staetsky L, Tunkel S, Ling T (2012), Case management for at-risk elderly patients in the English integrated care pilots: observational study of staff and patient experience and secondary care utilisation

Smith J, Wistow G, Holder H, Gaskins M (2019), Evaluating the design and implementation of the whole systems integrated care programme in North West London: why commissioning proved (again) to be the weakest link