When formulating the vision for integrated care, it is important to identify all the relevant stakeholders and talk to them about the need for change. Clinicians, commissioners and patients all need to be listened to so that they can express their concerns, share expectations and offer solutions. Each stakeholder group will have different priorities, and it is crucial that the vision is co-produced and regularly communicated to bring them fully on board.
Developing an inclusive vision
To ensure the vision is inclusive and informed by a variety of perspectives, leaders may have to think about:
· consulting all stakeholder groups to find out if/what change is needed and how it would affect them
· building consensus around the vision by using the expert panel or Delphi process
· checking if the vision is shared amongst stakeholders. Tools such as the sustainability model can be used to assess the level of engagement and help predict the likelihood of sustainability for your improvement initiative.
The final vision needs to be detailed and nuanced enough for all those affected to understand the benefits of the change, and their place in the system. Integration is a complex change, and it is important to consider the enablers and barriers to change at all levels of the healthcare system. Each individual, team and organisation needs to be clear what is expected of them, what resources are required, and in what timeframe. If they don’t agree with the vision or are not prepared for change, there is a risk that the vision will not be achieved because of a lack of understanding or commitment.
‘Each stakeholder group will have different priorities, and it is crucial that the vision is co-produced and regularly communicated to bring them fully on board.’
Dr Rustam Rea, consultant in diabetes and acute general medicine and clinical lead, Oxfordshire Integrated Diabetes Care Programme team
Communicating the vision
Once there is a reasonable degree of consensus, the vision for integrated care needs to be communicated and shared more widely. This is an ongoing job; the vision should be frequently revisited, reworked and recommunicated to make sure there is alignment with other change programmes and initiatives, and that all stakeholders remain engaged and supportive.
A striking insight from the NHS Confederation on delivering change in the NHS is that “the success or failure of NHS reconfiguration programmes largely depends on good communications and engagement.” Their 2014 report, Reconfigure it out: Good practice principles for communicating service change in the NHS, sets out eight ‘L’s’ for change programmes:
· Leadership: excellent leadership is needed to drive the programme
· Language: describe services clearly and consistently
· Let clinicians speak and support them: a strong and honest narrative is needed, for clinicians to deliver in their own voice
· Long-term improvements: be clear about timescales and the risks of doing nothing
· Learning: local history, best practice and evidence should inform reconfigurations
· Leverage: choose the right spokespeople and don’t assume the loudest stakeholders speak for all
· Local versus regional: stakeholders don’t necessarily live in NHS configurations
· Levels of engagement: reach as many people as possible, before and during public consultation
Delays, duplications and compromised diabetes care led our team to explore other ways of working across local diabetes services in Oxfordshire. One of the first tasks was to develop a shared vision of the new service, which involved identifying and consulting with all stakeholders with an interest in the project. Initially our stakeholders included clinicians in primary, secondary and community care, the CCG, patient groups and other organisations involved in providing diabetes care. Over time this list evolved to include other specialties related to diabetes as we realised the need for closer working.
The integration process has not always been easy, but despite the challenges we have faced, what has kept our stakeholders engaged is the shared vision of improving care for patients with diabetes. Some of the issues we experienced with developing and communicating our vision include:
Engagement across services
Engaging with primary care practitioners whose experience of working with secondary care specialists in diabetes or in other areas was mixed. Revisiting the vision and aligning it with higher level visions when local or national programmes were introduced, for example the sustainability and transformation programme. Learning that some team members were unsure about their role in delivering the vision, and unable to seek wider engagement and support from the groups they represented.
Dealing with leadership changes
Restating the vision multiple times to stakeholders as leadership within the CCG changed, which understandably caused frustration amongst those who have been part of the programme from the beginning.
‘If you are a leader working towards integrated care, it is essential to communicate the vision and relate it to everybody involved so that they can recognise the change required of them, and most importantly to revisit and recommunicate the vision as you go.’
Dr Rustam Rea
Developing an integrated service and working with a group of stakeholders from different organisations on a long-term programme is more than going through an agenda and updating the group on progress. It is important to be honest about the process and timescales, especially if things take longer than initially expected. It is also crucial to check that buzzwords such as ‘integration’, ‘care planning’ and ‘whole person care’ have not become over-used catch phrases that lose meaning over time.
What we did particularly well was ensuring strong clinical leadership from the diabetes consultants and local GPs. We also established a process of continual engagement with primary care staff, although we do need to think about ways of listening to the voices of those who are less directly involved in the project.
The integration process has highlighted the importance of convincing the team members that we are all leaders of change, and we need to be flexible, courageous and resilient as a team and when sharing our vision with the wider group of stakeholders.