The Care Quality Commission were instructed 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. The final report which included insights from a relational audit co-created with our support. It concludes that:
“We have seen 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.
Feedback from the relational audit highlighted that across the systems, people felt most positively about treating each other fairly, and in being open and honest in their dealings with one another. Trust and openness facilitated joint-working, and the reviews revealed how trust between partners enabled practical solutions to be developed to resolve system problems.
In senior leaders, collaboration was evident where partners demonstrated a shared understanding of system challenges and a shared responsibility for system performance. For example, leaders in one system had a shared view of the reasons for rising A&E attendances, agreeing ‘one version of the truth’ from which they could collectively act. In another system, partners jointly commissioned an independent review into their pathways; this meant that the findings from the review and responsibility for addressing them were jointly owned.
In response to the relational audit, people responded negatively about their ability to take on risks that served wider system goals without fear of criticism or failure. We observed silo working at all levels in our reviews, such as decisions taken in one organisation without consideration of wider system implications. Rather than working to common goals for the benefit of people who use services, people could revert to protecting their own roles and organisational aims defensive behaviours and ‘blame cultures’ that sharpened divisions between partners. The pressures of performance targets and financial constraints could exacerbate feelings of ‘them and us’.
Changes in leadership can slow progress in the development of the mature relationships required to set out a long-term vision and drive change. Some systems were also working to overcome deep-rooted relational fractures and cultural differences between their organisations. The reviews found that new leadership could reset previously difficult relationships, although these relationships needed time to embed. Where time is invested in relationships, there is a greater chance of success. Where there was a good level of trust and understanding between system partners, and where they could look beyond organisational priorities and performance, this created a positive platform for system working.