The Care Quality Commission were instructed by government to review 20 local health and care systems to understand how services are working together to meet the needs of people who move between health and care services. Following publication of the Beyond Barriers report in July 2018 further reviews have been conducted in autumn 2018.
We acted as specialist advisors with Whole Systems Partnership in the development and use of a relational audit tool in the review process.
The question each review asked was: “How well do people move through the health and care system, with a particular focus on the interface, and what improvements could be made?”
It is this emphasis on the interface, where systems, organisations, teams and individuals relate to one another, that required an approach examining relationships. It was clear that such an approach in a system review would be innovative and exploratory and had the potential to reveal evidence and information that would be crucial to improving the quality of health and care for the older person.
In a series of co-creation planning workshops relating to Local System Reviews a consistent issue raised by stakeholders was the importance of stakeholder relationships in achieving integration and personalised care. Effective multi-disciplinary working is imperative at all levels of interface – operational, organisational, and between system leaders – to achieve the best care.
Research links the quality of such relationships to health outcomes at a local level, better relationships linked with less physical illness and cognitive decline and with lower number of hospital visits and lower health costs. By focussing on such relationships, and highlighting variation in effective cross system collaboration, CQC aimed to identify where additional support is needed and enable sharing of good practice to secure the best outcomes for service users in all areas.
Having reviewed a variety of approaches to the relational dimension of system working, CQC chose to include a relational audit tool in their Local System Review methodology. In workshops with CQC, Relationships Foundation and Whole Systems Partnerships facilitated the co-creation of an audit tool, drawing on methodologies developed by each organisation.
The anticipated benefits of using such an approach were to:
- Introduce a common framework to describe how relational factors can be understood and developed in local health and care systems;
- Give a common understanding of the strength of relationships in local systems as identified through the audit tool across the 20 systems;
- Identify and agree on aspects of relationships that would benefit from attention in a system;
- Provide the potential for an ‘ongoing’ method to take the temperature of those relationships over time to measure improvement and impact;
- Open up the potential to drive forward the joint agenda and improve outcomes for the local community through better relationships, better knowledge sharing, common objectives and improved collaboration.
Overall, the Local System Reviews concluded that:
“system working relies on people working within health and care organisations to have a common vision, purpose and shared endeavour. Relationships are fundamental to joint working. Collective goals, collaborative decision-making, and sharing of risk are indicators of mature relationships, underpinned by multi-disciplinary and multiagency working on the ground. For this to happen there needs to be effective system leadership both locally and nationally. Locally, there needs to be a shared understanding of local needs, clear agreements about the roles of different partners, clear priorities and action plans which will make it easier for local leaders to collaborate across the system.
Local services can provide better and more joined-up care for people when different organisations work together across in a system. Nationally, there is a need to create the right incentives for integration and joint working in local systems. Leaders need to have the ability to work across organisational boundaries and prioritise system outcomes, and look beyond what they are accountable for at an organisational level. System accountability is required. Future system working will need to include aligned performance measures, aligned oversight and regulation, and funding to incentivise joint commissioning across health and social care.”
Better health and care outcomes for people rely on good relationships at all levels of services. The best ones are characterised by aligned visions and values, open communication, trust and common purpose.
Effective system working relies on relationships. In the systems that were reviewed, leaders who invested in building relationships and forming a consensus through a shared vision were able to address difficult issues through collaborative problem solving with openness and honesty. System leaders who have an understanding and appreciation of each other’s roles and responsibilities were also better able to build relationships that improved outcomes for people.
Even in systems that performing poorly according to some national indicators there are people at all levels working in health and social care who have successfully developed strong relationships, driven by a shared strategic vision for doing what is best for the people in their communities. Sometimes there were good individual relationships yet organisational drivers can act as a barrier to joined-up working.
Illustrative examples of free text responses alongside the relational audit include:
“Relationships are open and honest on the whole, and this really benefits the way we work together.” Operational manager, health commissioning organisation
“Individuals build relationship based on respect and trust but this does not work on an institutional level” Social care commissioning organisation.
“The system simply doesn’t operate as a system. The needs of individual organisations take priority over the needs of the elderly people we are supposed to be here to serve, the role of prevention is consistently ignored and truly collaborative working is poor or nonexistent.” Senior executive, multiple organisation types selected
“I believe there has been a significant improvement across the organisation and those of our partners and stakeholders… We have a [team] that meets and works together daily in a non-blame manner to get the best result for patients… The benefits and risks are shared. There are now integrated roles and focus and it is so much better for patients and staff.” Operational manager, health commissioner
“[The local authority] and [clinical commissioning group] have generally had very good working relationships with providers but these have been compromised by an aggressive stance on funding, which is cost-reduction led, and rarely needs led. As a result, the system puts people at risk.” Senior executive, social care provider
“There is a vast, untapped resource in the community that is not only under-recognised, but actively undermined by current commissioning and partnership arrangements. The competitive nature of commissioning acts as a deterrent to genuine partnership and creates an atmosphere of mistrust.” Operational manager, VCSE sector