The King's Fund Integrated Care bulletin editorial - "One system, one budget"

Merav Dover, Chief Officer of Southwark and Lambeth Integrated Care, has written the editorial for this month's The King's Fund Integrated Care bulletin (August 2015).

The editorial read:


"One system, one budget": learning from the experience of Southwark and Lambeth Integrated CareMerav Dover, Chief Officer, SLIC

Creating a truly integrated care system is simple in theory, but much more difficult in practice. In Southwark and Lambeth we have been developing integrated care for three years and we have learnt a great deal along the way. During this time Southwark and Lambeth Integrated Care has achieved much to be proud of.

Local people and staff from across health and social care have been working together to design and test new approaches that have meaningfully improved people’s experience of care. For those of you embarking on new models of care, I hope it’s helpful to hear about our experiences.

For us, integrated care is about organisations coming together as one system with one budget, to increase the value of care we provide for local people, so they can lead healthier and happier lives. Any one organisation cannot do this alone.

As the partnership includes NHS foundation trusts, local authorities, clinical commissioning groups, general practice, the community sector and people living in Southwark and Lambeth, arriving at this shared vision was challenging and took time to get right. Initially we underestimated the extent to which we would need to change behaviours to deliver integrated care: the importance of supporting people to take control of their own health and wellbeing, of moving from treating conditions to preventing them and of moving from a prescriptive approach to a partnership approach. We now recognise that the most successful solutions are those that are co-designed by frontline staff and local people, and we have citizen representatives in all of our governance meetings.

We have worked tirelessly to build strong relationships within our partnership. Transformation is built on hard-won trust and as trust has built up we have overcame barriers to integration, such as having to let go of organisational or professional power and control. In building trust, we have become more explicit about the need to shift resource into communities and to continue to do more to involve the voluntary sector.

We now have a greater understanding of how to make change happen. We were lucky to have investment from Guy’s and St Thomas’ Charity and this was used to test different approaches. We have learnt the importance of having good methodology for testing and adapting initiatives. GPs used the investment to develop their collaborative leadership and to give themselves the time to lead and develop new ways of working; this made a big difference. We’ve not yet wholly cracked the issue of time – freeing people up to co-design and try new ways of working. We’ve learnt the hard way that neither top-down nor bottom-up change works and we must bring the two together. To deliver transformational change across the system, it is critical to hard-wire accountability into the organisations for each of the changes we commit to and we are working on this.

Across Southwark and Lambeth we have a rich pool of great leaders and world-class clinicians at our disposal and we have not been shy in taking advantage of it. This has been hugely important to us in terms of our ability to drive change and deliver new ways of working. So, it won’t surprise you to learn that we went bust on our timescales. Behaviour change, building trust and co-designing and testing solutions takes serious time, but taking short cuts takes even longer. We’ve now learnt to build time for these activities into our plans.

We were always good at being self-critical and we’re now learning to shout about our successes; success needs to be celebrated regularly to continue to reignite enthusiasm and a commitment to do more. Notably, the overall trend in emergency admissions for people aged over 65 living in Southwark and Lambeth appears to be flat, despite evidence of significant growth in other parts of London and England, and we have an increasing number of personal stories suggesting that our work is having a positive impact on people and their experience of care.

Although we can be proud of what we’ve achieved, we still have plenty to do. We have set out the partnership commitments that we want to realise by April 2016. As individual organisations we can’t tackle the challenges we face, but together we have the ability to improve care for our vibrantly diverse urban community.

Merav Dover
Chief Officer, Southwark and Lambeth Integrated Care