Integrated care: working well together

They will, say NHS England, improve population health, create ‘shared leadership and action’, and pull together primary and specialist health services, mental health teams and social care. Daniel Allen visits Dorset and reports on an ICS in action.

By 2029, ICSs will cover the whole country, improving outcomes, reducing inequalities, and enhancing financial and operational performance. ‘Local services can provide better and more joined-up care for patients when different organisations work together in this way,’ says NHS England.

The vision is bold and the theory clear. But what will ICSs mean in practice? In what ways might they make care better for patients, and how will they affect the working lives of physios and other allied health professionals (AHPs)?

Already a third of England’s population is covered by an ICS, including people in Dorset. Our Dorset, the name given to the local ICS, is a partnership of several organisations, including the county’s clinical commissioning group, five foundation trusts, three councils and Public Health Dorset. 

Our Dorset’s lead AHP is a physiotherapist, Hilary Hall. She is also head of therapies for Poole Hospital NHS Trust, but in her ICS role she has no responsibility for staffing or budgets – that lies with the respective partners in the ICS. Instead, her focus is on turning the concepts laid out by the centre into local action. 

‘My role is about encouraging collaboration,’ she says. ‘Whether it’s the Long Term Plan, the Five Year Forward View, GP contract reform or the Interim People Plan for the NHS, my responsibility is to understand the potential of those plans and their impact on Dorset in terms of the AHP workforce.’

An early step in that process was to establish an AHP council, a body of ‘keen, influential, enthusiastic’ staff, Ms Hall says, who will help her deliver her remit. Council members are drawn from Our Dorset’s partner organisations and Bournemouth University.

Working collaboratively

Carol Thorne, Poole Hospital’s inpatient therapy lead, sits on the council. She says its purpose is to look at the skillset of AHPs across the patch and how they can ensure they are at the forefront of developing services for the benefit of patients and service users.

‘I feel my role is in sharing experiences from an inpatient point of view and looking for opportunities for collaborative working across the system, because I think there are great advantages in doing that,’ Ms Thorne says.

The council will develop Our Dorset’s AHP strategy, provide a hub of AHP expertise, and help raise the profile of AHPs to maximise their contribution to services remodelled by the ICS.

It is early days for the council but Ms Thorne says that already it is providing opportunities to network with other AHPs across the patch.

‘One project we’ve started looking at is around moving and handling training for occupational therapists. I’ve been able to link with the principal occupational therapist with Dorset County Council. They have access to training already so we’re aiming to dovetail our training with theirs. That’s a direct example of something we’re working on through that link with the AHP council.’

When you build relationships across organisations, that helps across the patient pathway. We’re solving one issue but probably solving lots of other things at the same time – and that’s really positive.

Collaborative working is also extending to joint recruitment programmes, so that, for example, local trusts are not pitted against each other when trying to attract band five physios and OTs. 

‘It’s a brilliant opportunity to work together to attract new graduates to Dorset, which can be a challenge,’ says Ms Thorne. 

But working together is not without its challenges, especially if organisational culture does little to cultivate collaboration. 

‘In the past, we’ve been encouraged to think very much in silos and not necessarily look outside our own areas,’ she says. ‘We still need to make sure we’re providing an efficient and productive service but I think with the ICS there’s the opportunity for that system-wide thinking.

‘You’re able to be more strategic and longer term when you’re taking that approach, whereas when you’re looking at trying to resolve your own issues, it’s very short term and reactive. It’s quite a shift but as AHPs it’s a satisfying shift.’

Promoting FCP roles

Another therapist with a key part to play in the ICS is Janine Ord, Our Dorset’s project lead for supporting first contact practitioners (FCPs), a two-day-a-week role she combines with being an MSK physio and operational lead at the Royal Bournemouth Hospital.

‘The aim of the project is to take an ICS approach to how we can support the training, development and governance of first contact practitioner roles for Dorset,’ she explains.

‘We have four providers of core physiotherapy in Dorset which all, at one time or another, have done pilots for first contact roles. 

‘So this is about bringing them all together and seeing how as a system we can support training and development by combining the knowledge and skills we have within the physiotherapy departments and our advanced clinical practice roles, across the whole MSK pathway.’

In practice, that means making the most of the physiotherapy expertise in emergency care, and fracture, rheumatology, orthopaedic and back pain clinics, Ms Ord says. ‘How can we use that to give first contact practitioners the experience of thresholds for investigation, understanding diagnosis and the role of each of those clinics so they can be networked across the ICS and streamline care pathways for their patients?’ 

And what findings have emerged from the project?

‘That all the providers have placed highly experienced MSK physiotherapists into the first contact practitioner roles and they’re doing a really high quality job. We’ve got really good outcomes aligned with the national evaluation for the roles.’

She adds: ‘There’s increasing demand from primary care for these roles, so going forward we need to be realistic about the pace at which we can deliver suitably experienced clinicians to maintain that high level of quality.

‘Many of the skills required by first contact practitioners are very difficult to teach. They require a lot of experience with patients. We can speed the process up to a certain extent but it’s really important that these clinicians have seen a lot and a wide variety of patients throughout their clinical experience.’ 

Exciting opportunities

The project will end with Ms Ord presenting a paper to primary care networks in Dorset with recommendations on support, training and governance arrangements for FCP roles.

She believes the ICS is having an impact. ‘From my perspective, it’s taking the blinkers off as a physiotherapist and giving us the permission to see where we can have a wider impact on population health.

‘We’re looking at ways we can use the FCP model to support positive behaviour change, linking in with social prescribing and taking a positive view of the patient.

‘Feedback shows that patients value the shared decision making with the FCP role, and that’s really important for empowering patients to independently manage their own health.’

It may be too early to say for certain that government plans for integrated services are radically changing the way care is delivered but Ms Ord is optimistic. ‘This is the first step in a journey. At the moment, we’re still behaving in terms of separate organisations. But with the FCP approach aligned across Dorset, I can see us having placements for FCPs across the whole of the MSK pathway.

‘That will require them rotating to different organisations and I think that’s exciting. It breaks down the barriers and gets us collaborating.’

An NHS Long Term Plan implementation framework, published in June, lays out the approach ICSs should take in creating their five-year strategic plans. At 44 pages, it is not a document that every physio will find time to read. But Our Dorset AHP lead Hilary Hall is keen to ensure that staff at all levels are engaged with the local ICS and helping to shape the development of physiotherapy in line with government ambitions.

Joel Dunn, a neurological clinical specialist physiotherapist with Dorset Healthcare University NHS Trust, attended one of two workshops Ms Hall arranged for physios to reflect and share views on the physiotherapy workforce – topics such as flexible careers, rotational posts and split posts, for example.

It was an inspirational experience, Mr Dunn says. ‘My head was spinning, not only with the possibilities of how things may be, the opportunities and the excitement of being involved in meaningful change and cross-organisation working, but also with the little nuggets of ideas I took away and thought could be used well locally.’

He says there was a ‘positive energy’ between the organisations represented at the workshops ‘who at this stage appear committed to change and new ways of thinking.’

Louise Rich, who qualified as a physio in July last year, was also invited to attend the workshops. 

‘They wanted breadth of representation – people from different grades, different levels of post-registration experience – to give a variety of insights into how we can take the profession forward,’ she says. 

Until that point, the Dorset ICS was something she had heard mentioned but, by her own admission, had not really understood. 

‘I was very aware of the NHS Long Term Plan, but when I was asked to be involved, obviously I read up on the ICS and found out more.’ 

As a recently qualified physio, did she feel her contribution was valued?

‘Definitely. And what was really good was having the opportunity to talk to people who came from such different areas of physiotherapy. For example, there were people from the learning disability service and it was good to hear some of the challenges they face. 

‘I’m all about the patient, and I feel the ICS offers the opportunity for individuals to have greater control of their own health, care and wellbeing, which really ticks all my boxes. 

That’s definitely empowerment for them.’ 

Integrated care systems: are they working?

A study published last September by the King’s Fund reviewed the journey so far for integrated care systems. 

The report said ICSs represented a ‘fundamental and far-reaching change’ in how the NHS works but pointed out there was no national blueprint and their development was locally led.

The study, based on interviews conducted in eight of the first wave of ICSs, concluded there were ‘early signs of progress’ in delivering service changes but more time was needed to embed the changes and assess their impact.

‘The understandable desire to see change happen quickly needs to be married with realism about the scale and complexity of what is being attempted,’ the study said.

• A year of integrated care systems: reviewing the journey so far