Integrated Care Systems: Finding inspiration in unexpected places.

Hello Systems Thinkers,

This post recounts an email discussion a few of us had about an article Chris Ham of the the Kings Fund published last month on the subject of “Integrated Care Systems”, an NHS evolution of the concept of “Accountable Care Organisations”.  I shared an anonymised version of the email string with a friend in the systems/complexity community, who has an interest in the topic and he suggested I post it as a blog, so here it is.

The article in question can be found here:

It’s a good article and our critique was not of the article or the author, but rather on the approach it describes and lessons we might learn from elsewhere.  As ever, the views expressed here are personal and not necessarily those of our employers, or any other organisations we’re involved with.

A conversation began

We were first made aware of the article when a group member shared it and said:

It’s getting hard to keep up with all the changes!”

Another group member quickly replied saying:

“It’s interesting that success in this setup, in the absence of aligned formal accountability, rests on organisations’ abilities to maintain a partnership approach. The level of maturity in the relationships between acute, community, commissioning, local authority etc will impact massively on Integrated Care System development.”

I agreed and jumped in with a reflection and comparison of a past experience working on the development of an altogether different type of mega-project:

Infections team spirit

“I completely agree.  I’m reminded of my experience on the Heathrow Terminal 5 (T5) construction project.  BAA moved heaven and earth to create an environment and contractual arrangements where trust between parties could flourish and as a result barriers to delivering evaporated.  I happened to meet a chap who is now senior position on the Hinckley C project a couple of months ago, who had also worked on T5. He described the T5 project has having a unique “infectious team spirit”.  And he was right. It was quite special and I still feel inspired by what was achieved by the project team; which included may different organisations

That didn’t come about by accident though.  There was enormous effort made to develop the supply chain to a place where that could occur, and then very specific and revolutionary approaches to contracting and pooling risk used.  A decade before construction even began, they realised they would need to take a new approach and set about creating an environment on other projects to start nurturing the new culture and approach and to develop the supply chain to a place where it could deliver T5.  Prior to that, there was no way the UK construction industry would have been able to deliver T5 on time and to budget.

A serious and deliberate approach

They really focussed on building the team.  It was all very deliberate.  I think a similarly deliberate and long term approach to developing the technical capability, environment and culture will also be needed to support the creation of sustainable “Integrated Care Systems”.  

The T5 approach wasn’t an Integrated Care System, but it was absolutely an Integrated project delivery system.  I think there are a lot of parallels.

Have a read of these articles.  They set out what an incredibly challenging project it was and the approaches to contracting BAA pioneered in order to deliver it.:

Back to Integrated Care Systems

Back to the article about Integrated Care Systems.  This paragraph stands out for me:

“Mutual accountability hinges on the existence of a high degree of trust and respect between organisations and their leaders. It also requires the establishment of governance arrangements that support collaboration while respecting the statutory responsibilities of these organisations. Integrated care systems have no basis in law and they depend on the willingness of the organisations involved to think and act as part of a wider system even when it may not be in their interests to do so.“

It describes perfectly what was achieved on T5.  Apart from the final sentence:

and they depend on the willingness of the organisations involved to think and act as part of a wider system even when it may not be in their interests to do so.“

I’m not sure how likely it is managers and organisations will act against their interests and without addressing this, they might struggle in the long term.  The reasons it might not be in an organisation’s interests to act as part of a wider enterprise are systemic.  Like they did on T5, the job at hand is to identify those systemic drivers of behaviour and address them. 

Chris Ham does identify this as a potential difficulty in the article where he says:

“……..workarounds are inherently unstable, even in the most favourable circumstances, and can only be sustained for so long.  Informal mechanisms such as memoranda of understanding and partnership boards to underpin decisions about the use of NHS resources have a part to play but may break down when difficult decisions arise. ” 

It’s not easy in public services

The point about the T5 project is that they deliberately created an environment, structure and contracts that meant all organisations were incentivised to pull together and do whatever it took to deliver the project.  That is why it worked. There was no fairy dust involved. 

It’s probably harder to do this in public services than it is in the private sector, where there is less political interference allowing for a longer term approach and accountability is more easily traced.  Accountability for the delivery of T5 lay firmly with the management of BAA and the company’s shareholders would hold them to account. 

But T5 is still a source of inspiration

Even so, we shouldn’t underestimate just how impressive an achievement it was for BAA to deliberately invest in and build up the capability of the UK construction industry to be able deliver a project as large and complex as T5.  It’s a great place to look for inspiration.”

Happy 10th Birthday!

And by happy coincidence, this month is actually the 10th anniversary of the opening of T5.

I will raise a glass to the project this weekend.  Join me.

Systems Thinkers Anonymous